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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343617941
Report Date: 04/18/2023
Date Signed: 04/18/2023 11:15:39 AM

Document Has Been Signed on 04/18/2023 11:15 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:SAMUSENKO, LYUBOVFACILITY NUMBER:
343617941
ADMINISTRATOR:SAMUSENKO, LYUBOVFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 429-5752
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
04/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Lyubov SamusenkoTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Karyn Guerra met with Licensee, Lyubov Samusenko, for the purpose of an unannounced required - 1 year inspection. LPA observed a census of 12 preschool children supervised by Licensee and an adult assistant. Hours of operation are 7:00 a.m.- 6:00 p.m, Monday thru Friday. Off limits areas consist of the garage, laundry room, licensee’s daughter’s room and side and far back yard areas that are gated off. Licensee understands that child care children must not enter the off limits areas of the home.

All individuals subject to criminal background review have obtained a criminal record clearance. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A health and safety inspection was conducted in all areas accessible to children. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated that there are no weapons nor poisons in the home. Toxic and hazardous items were appropriately stored, inaccessible to children. Fireplace is appropriately barricaded to prevent access by children. Fire Drills have been conducted and documented.

LPA reviewed staff and children's files and observed current in person EMSA CPR and First Aid certification for Licensee expiring 7/2023. Adult assistant is also CPR certified. Mandated reporter training was verified for Licensee. LPA discussed mandated reporter language needs. LPA observed immunization records, emergency identification, and signed parents rights in children's files. LPA provided form LIC627 for Consent for Emergency Medical Treatment, and additional forms for assistant.

report continued on 809-C.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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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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: SAMUSENKO, LYUBOV
FACILITY NUMBER: 343617941
VISIT DATE: 04/18/2023
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No infant children are in care. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

No children in care require medications. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department.

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: https://www.ada.gov/childqanda.htm.

Exit interview conducted and report was reviewed with the licensee, Lyubov Samusenko. A Notice of Site Visit was given and must remain posted for 30 days. To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

In the areas that were evaluated, no deficiencies were cited during inspection.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC809 (FAS) - (06/04)
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