343618276-1-27-2022-03-CC-ATIY-CB3REP-20220127115751

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343618276
Report Date: 01/27/2022
Date Signed: 01/27/2022 11:58:02 AM

Document Has Been Signed on 01/27/2022 11:58 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:	KISELEV, YELENA		FACILITY NUMBER:	343618276
ADMINISTRATOR:	KISELEV, YELENA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 704-8155
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95827
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 3	DATE:	01/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Yelena Kiselev		TIME COMPLETED:	12:15 PM

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 January 27, 2022 at 10:30 AM, Licensing Program Analyst (LPA) Alize Tillery met with licensee Yelena Kiselev for the purpose of an annual required 1 year inspection. The facility’s days and hours of operation are Monday - Friday from 7:00 AM to 9:00 PM. LPA observed care and supervision of 3 children supervised by the Licensee. Licensee's adult son assisted in translating communication between LPA and Licensee; Licensee's primary language is Russian. All individuals subject to criminal background review have obtained a criminal record clearance. A health and safety evaluation was conducted in all areas accessible to children. Off limit areas consist of: the entire upstairs floor and the garage. LPA observed a 2A10BC fire extinguisher, first aid kit and functioning smoke and carbon monoxide detectors. Per licensee, there are no weapons in the home. No children were observed in parked cars. Toxic and hazardous items are inaccessible to children, and safe toys were observed. Licensee understands that activity jumpers are not to be used during day care operation hours. LPA reviewed children’s files for the 3 present day care children; files were observed to be missing the LIC 627 – Consent for Medical Treatment form. LPA provided a list of documents to Licensee that lists each document to be kept in children files. Required postings and the children’s roster were observed. Licensee has record of conducting fire drills at least every six months. Per record, last drill was conducted on 07/2021. Licensee is due for a fire drill this month, 01/2022. LPA observed COVID19 posters and current guidelines were discussed. LPA observed licensee’s CPR and First Aid card which expires 12/2023. Licensee’s and all other adult files were reviewed and were observed to be complete. LPA discussed the requirement of renewing mandated reporter training every 2 years. Licensee’s Mandated Reporter Training is current and expires on 04/16/2023. Continued on LIC809C…

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

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 01/27/2022 11:58 AM - It Cannot Be Edited

Created By: Alize Tillery On 01/27/2022 at 11:23 AM

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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: KISELEV, YELENA	FACILITY NUMBER: 343618276
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(7)

Operation of A Family Child Care Home

(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that children did not have the consent for medical treatment form on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2022
	Plan of Correction
1 2 3 4	Licensee will submit to LPA Tillery proof of completed forms.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Seychelle De Luca

LICENSING EVALUATOR NAME:

Alize Tillery

LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

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: KISELEV, YELENA	FACILITY NUMBER: 343618276
	VISIT DATE: 01/27/2022

NARRATIVE

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Licensee's fees are current.

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 submitting 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: http://www.ada.gov/childqanda.htm

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/process.

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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://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.

A deficiency is cited on the following 809D page.

A notice of site visit was given and must remain posted for 30 days. Exit interview was conducted and report was reviewed with the Licensee, Yelena Kiselev.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

LIC809 (FAS) - (06/04)

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