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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618277
Report Date: 09/22/2023
Date Signed: 10/19/2023 01:20:31 PM

Document Has Been Signed on 10/19/2023 01:20 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:KUBRAKOV, ANGELINAFACILITY NUMBER:
343618277
ADMINISTRATOR:KUBRAKOV, ANGELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 459-7273
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
09/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Angelina KubrakovTIME COMPLETED:
01:45 PM
NARRATIVE
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On Thursday, October 19, 2023, Licensing Program Analyst (LPA) Amanda Sutter met with Licensee, Angelina Kubrakov, for the purpose of an unannounced annual inspection. There were no children present at the facility. All individuals subject to criminal background review have obtained a criminal record clearance. Facility hours of operation are 24/7.

A health and safety evaluation was conducted in all areas accessible to children. Off-limit areas include: garage, entire upstairs, and bedroom 4. Licensee acknowledged that children may never enter these off-limit areas. LPA observed that the facility is clean, safe, sanitary, and in good repair. LPA observed a functioning smoke detector, carbon monoxide detector, and a full 2A10BC fire extinguisher. The facility has adequate toys that appear to be safe for children to use. The licensee stated there are no weapons or poisons in the home. LPA observed a fireplace to be barricaded according to regulation. LPA did not observe stairs to be barricaded, but observed that licensee owns a gate for the stairs. LPA reviewed facility roster and verified that all children enrolled are over the age of five. LPA observed a pool fully enclosed by a fence with a self-latching gate that swings away from the pool. The backyard is fenced.

LPA reviewed four children’s files which were observed to be complete. Required postings and the children’s roster were observed. The facility has record of conducting fire drills at least every 6 months. The last fire drill was conducted 9/21/2023. Licensee’s CPR/First Aid card expires 11/2024. Licensee’s Mandated Reporter certificate expires 1/30/2024. Licensee’s first language is not English, therefore she is not required to renew this training once it expires. Licensee understands that trainings must be completed every two years.

LPA verified that the annual fees are current. Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

PAGE 1. REPORT CONTINUES ON LIC809-C
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KUBRAKOV, ANGELINA
FACILITY NUMBER: 343618277
VISIT DATE: 09/22/2023
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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 [or facility representative] 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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/resources/child-care-centers/.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

A notice of site visit was given and must remain posted for 30 days. Based on the inspection, no citations have been issued. Exit interview conducted and report was reviewed with the licensee Angelina Kubrakov. During the exit interview, the Licensee Angelina Kubrakov, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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