313624111-11-19-2021-03-CC-JMCN-C8WNGP-20211119092728

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 313624111
Report Date: 11/19/2021
Date Signed: 11/19/2021 09:27:40 AM

Document Has Been Signed on 11/19/2021 09:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME:	PICHSHULINA, MARINA		FACILITY NUMBER:	313624111
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 1	DATE:	11/19/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Marina Pichschulina		TIME COMPLETED:	09:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/19/2021, Licensing Program Analyst (LPA) Jeremey McClain conducted a Pre-Licensing inspection with applicant Marina Pichschulina. Applicant is applying for a Small Family Child Care License. A health and safety inspection of the home was conducted. Applicant resides in a two-story home consisting of four bedrooms, three bathrooms, a living room, a dining room, a kitchen, a garage, a laundry room, and a fenced patio. The off-limits areas in the home will be the upstairs, the office on the first floor, the laundry room, the and the garage. Off-limits areas will remain inaccessible to children by closed doors and or supervision. Applicant has placed a gate at the bottom of the stairs to prevent access to children in care. Applicant plans to operate Monday through Friday from 8 am to 12 pm. Toxic and hazardous items are inaccessible to children. Functioning smoke and carbon monoxide detectors and a 2A10BC fire extinguisher were observed in the home. Current pediatric CPR and first aid training was verified. Applicant stated there are no weapons in the home. Applicant has a hot tub in the backyard that is appropriately covered and locked on two sides. There is a latching bar in the middle that prevents the cover from being lifted more than 1 inch. LPA advised applicant to add locks on the two sides that don’t currently have them. Applicant has provided proof of Immunization for Pertussis, Measles and Influenza. Tuberculosis clearances for all adults in the home have been provided. Applicant has completed the required AB1207 Mandated Reporter training. Applicant understands that the training must be completed once every two years, and that Mandated Reporter trainings offered outside of http://childcare.mandatedreporterca.com/ , must be approved by the department. Report Continued on the following page...

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: PICHSHULINA, MARINA	FACILITY NUMBER: 313624111
	VISIT DATE: 11/19/2021

NARRATIVE

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All individuals subject to criminal background review have obtained a criminal record clearance.

Applicant understands that any assistants for the childcare must also obtain the following: EMSA certified CPR and first aid training, immunizations for measles Pertussis and Influenza, complete AB1207Mandated Reporter Training, and complete eight hours of preventative health and safety training.

Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. Applicant was encouraged to maintain supervision at all times. LPA advised applicant that 100% supervision is required in areas outside of the home that are unfenced.

LPA explained to applicant that if they move and want to continue to provide care, they must submit a change of location application and have the new home inspected.

Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within seven days to remain in compliance.

Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction. Applicant understands that if they want to make any off-limit area an ON-limits area, they must notify licensing and LPA must do an inspection BEFORE children are allowed in the area.

Records, postings and reporting requirements were discussed. LIC311D was provided and discussed.
Applicant understands that children’s records are to be maintained according to Title 22 regulations and be accessible to licensing for up to three years after the child is no longer enrolled. Applicant stated that she currently doesn’t have liability insurance. Applicant understands that clients must sign and complete form LIC 282 until she obtains insurance. Applicant understands that their License, Emergency Disaster Plan, and the Parents Rights Poster must be posted in the home. LPA discussed the necessity for applicant to obtain and record children’s immunizations on form PM 286.

LPA discussed capacity and ratios with the applicant. Applicant understands that children in the home under the age of 10 will count towards her ratio and capacity.
Report continued on the following page.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: PICHSHULINA, MARINA	FACILITY NUMBER: 313624111
	VISIT DATE: 11/19/2021

NARRATIVE

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LPA informed applicant that all inspections after today will be unannounced.

Immediate Civil Penalties were discussed.

The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

This facility evaluation report was reviewed and discussed with the applicant.

Applicant was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

LPAs also provided the childcare advocates e-mail address for the advocates in order to be added to the quarterly newsletter mailing list. childcareadvocatesprogram@dss.ca.gov

As of today, the applicant is approved for a Provisional Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only; or up to 8 children with no more than 2 infants, with 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021

LIC809 (FAS) - (06/04)

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