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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313624154
Report Date: 07/20/2023
Date Signed: 07/20/2023 02:58:35 PM

Document Has Been Signed on 07/20/2023 02:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FANHA, NATALIYAFACILITY NUMBER:
313624154
ADMINISTRATOR:FANHA, NATALIYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 273-2493
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
07/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Olha Naraivska and SolomiiaFeshanets- AssistantsTIME COMPLETED:
03:30 PM
NARRATIVE
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An unannounced case management inspection is conducted today to observe the operation of the facility.

Present at time of inspection were two assistants and 11 day care children. Licensee was not present at facility when LPA arrived. Licensee arrived a short time later.

See 809 -D for deficiency.

Notice of site visit posted at time of inspection.
Exit interview conducted and appeal rights given at time of inspection.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Katrina Owens
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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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Document Has Been Signed on 07/20/2023 02:58 PM - It Cannot Be Edited


Created By: Katrina Owens On 07/20/2023 at 01:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FANHA, NATALIYA
FACILITY NUMBER: 313624154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2023
Section Cited
CCR
102370(d)

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Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:

(1) Obtain a California clearance or a criminal record exemption as required by the Department
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Licensee had Mr. Ihor Labiak get fingerprinted and submitted the completed live scan form LIC 9163 to CCLD.
Deficiency cleared.
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This requirement was not met as licensee stated she rents a room to Mr. Ihor Labiak. He has been at the home for approximately 2 weeks. He does not have a criminal record clearance. This is an immediate risk to children.
Civil penalty assessed.
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LIC 9224 given and explained to licensee at time of inspection.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Keven Peters
LICENSING EVALUATOR NAME:Katrina Owens
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023


LIC809 (FAS) - (06/04)
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