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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313624882
Report Date: 09/06/2023
Date Signed: 09/06/2023 10:14:31 AM

Document Has Been Signed on 09/06/2023 10:14 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DOLINA, ELENAFACILITY NUMBER:
313624882
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 10CENSUS: 4DATE:
09/06/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Elena DolinaTIME COMPLETED:
10:20 AM
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On Wednesday, September 6, 2023, Licensing Program Analysts (LPAs) Tanya Washington and Lea Habtom met with Licensee Elena Dolina for an unannounced case management inspection to increase capacity to the maximum number of 14 children. Licensee has sufficient experience to operate a large capacity license. During today's inspection LPAs observed care and supervision of four children. All adults residing in the home have obtained the required fingerprint clearances. Facility hours and days of operation are Monday- Thursday from 7 AM to 6 PM and Fridays from 7 AM to 4 PM.

Licensee owns the home, control of property has been verified. LPA discussed capacity options with and without an assistant and when the Licensee or the assistant are alone they divert to small license ratio requirements.

On August 29, 2023, Roseville Fire Prevention granted a fire clearance.

The off limit areas in the home are: entire second floor and garage. Licensee acknowledged that children may never enter the off limit areas of the home. There are no bodies of water on the premises. Per licensee, there are no weapons on the premises. Infant safe sleep guidelines were discussed.

Licensee's CPR and First Aid is valid until 09/2023. License has already renewed the required CPR and First Aid certification, however does not have a new card yet.

EFFECTIVE TODAY, 09/06/2023 THE FACILITY IS LICENSED TO SERVE A MAX. CAP OF 12 (WHEN THERE IS AN ASSISTANT PRESENT): WITH NO MORE THAN 4 INFANTS OR MAX CAP 14 - NO MORE THAN 3 INFANTS. 1 CHILD IN KINDERGARTEN OR ELEMENTARY SCHOOL AND 1 CHILD AT LEAST AGE 6.

This report was reviewed with Licensee Elena Dolina. Licensee confirmed that there are no Registered Sex Offenders residing in the facility. Notice of site visit posted.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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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