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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622895
Report Date: 04/22/2022
Date Signed: 04/25/2022 08:40:05 AM

Document Has Been Signed on 04/25/2022 08:40 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:BEREZENKO, IRINAFACILITY NUMBER:
343622895
ADMINISTRATOR:BEREZENKO, IRINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 752-9810
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
04/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Olga MeahalevaTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Pascual met with Facility Representative Sara Yashenko and Olga Meahaleva for an annual/random inspection. The licensee was out of town. LPA toured areas of the home accessible to the children. Licensee acknowledged that children may never enter these off-limit areas. Licensee stated there are no new residents in the home, and all adult residents have criminal record clearances.

Upon arrival today’s census was seven children, three were infants and four are preschool aged, one assistant only. Another assistant was brought in to help during the inspection.

Upon entry to the facility LPA witnessed the stairs were not barricaded with children under 5 present. The provider barricaded the stairs right after being notified by LPA.

Also witnessed upon arrival was an infant sleeping in a swing. LPA informed provider this was not within regulation of safe sleep. Provider moved the infant and placed the infant in a pack in play.

LPA witnessed the pack in play with hanging objects above which is not within Safe Sleep regulations. Provider removed the hanging objects when LPA requested.
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Michelle Pascual
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
Document Has Been Signed on 04/25/2022 08:40 AM - It Cannot Be Edited


Created By: Michelle Pascual On 04/22/2022 at 12:14 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: BEREZENKO, IRINA
FACILITY NUMBER: 343622895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(3)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPA witnessed the stairs without a barricade upon arrival which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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LPA informed provider and the stairs were immediately barricaded.
Type A
Section Cited
CCR
102416.5(d)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA witnessed the age groups out of ration (three infants and four preschool children) without any childern aged 6 or older/attending kindergarten.
POC Due Date: 04/22/2022
Plan of Correction
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LPA informed the provider of this issue and another staff member was brought in to help provide care while LPA was present. Staff member is cleared. Facility is aware of ratio and was provided a form to reference for future use.
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:Roxana Saravia
LICENSING EVALUATOR NAME:Michelle Pascual
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 04/25/2022 08:40 AM - It Cannot Be Edited


Created By: Michelle Pascual On 04/22/2022 at 12:14 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: BEREZENKO, IRINA
FACILITY NUMBER: 343622895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA witnessed this with more infants and preschool aged children without any school aged children present.
POC Due Date: 04/22/2022
Plan of Correction
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LPA informed staff member of this and another staff member was brought in to assist in providing care and the individual was cleared. LPA witnessed this staff member.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Roxana Saravia
LICENSING EVALUATOR NAME:Michelle Pascual
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 04/25/2022 08:40 AM - It Cannot Be Edited


Created By: Michelle Pascual On 04/22/2022 at 12:14 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: BEREZENKO, IRINA
FACILITY NUMBER: 343622895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)(3)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (3) There shall be no objects hanging above or attached to the side of the crib.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. This was witnessed by LPA seeing a hanging object above the pack in play.
POC Due Date: 04/22/2022
Plan of Correction
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LPA brought this to their attention and the hanging device above the pack in play was immediately removed. Facility understands this is not allowed.
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation by LPA , the licensee did not comply with the section cited above. This was witnessed tby not observing any sleep logs.
POC Due Date: 05/06/2022
Plan of Correction
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Licensee shall implement sleep logs immediately and keep them in a file. LPA discussed safe sleep regulations.
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:Roxana Saravia
LICENSING EVALUATOR NAME:Michelle Pascual
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 04/25/2022 08:40 AM - It Cannot Be Edited


Created By: Michelle Pascual On 04/22/2022 at 12:14 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: BEREZENKO, IRINA
FACILITY NUMBER: 343622895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)(1)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This plan shall be signed and dated by the infant’s authorized representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. No sleep plans were in place.
POC Due Date: 05/06/2022
Plan of Correction
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Licensee will provide all LIC 9227 plans for all infants. LPA discussed infant regulations.
Type B
Section Cited
CCR
102425(c)(2)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPA did not witness any LIC 9227s in place for infants in care.
POC Due Date: 05/06/2022
Plan of Correction
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Licensee will provide all LIC 9227 for all infants. LPA discussed infant sleep regulations.
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:Roxana Saravia
LICENSING EVALUATOR NAME:Michelle Pascual
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022


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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: BEREZENKO, IRINA
FACILITY NUMBER: 343622895
VISIT DATE: 04/22/2022
NARRATIVE
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LPA observed current CPR/First Aid certificate (exp: 11/2023) and Mandatory Reporter training was not renewed and LPA explained the renewal process.

LPA discussed safe sleep regulations with provider. Provider did not have safe sleep logs nor the LIC 9227 for infants.

LPA witnessed posted License, Parents' Rights Poster, facility sketches, and Emergency Disaster Plan. LPA discussed recent changes in licensing requirements, including SB 277 and SB 792 pertaining to immunization requirements for children and staff.

LPA observed hazardous items (detergents, cleaning compounds, medication, sharp utensils, and other items that could pose a danger to children in care). properly stored out of children's reach. There is a working telephone in the home.
Licensee stated there are no weapons in the home. Fire extinguisher, carbon monoxide and smoke detector meet regulation. LPA observed fire drills documented. Toys appear to be safe and in working order. The backyard is fenced.

This provider is not currently providing IMS services to children in care. 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.



SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Michelle Pascual
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
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Page: 6 of 9
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: BEREZENKO, IRINA
FACILITY NUMBER: 343622895
VISIT DATE: 04/22/2022
NARRATIVE
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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.
LPA verified the annual fees are current. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the Licensee can request to be added to the distribution list to receive Quarterly Updates.

LPA reviewed and discussed this facility evaluation report with the Licensee. LPA provided a Notice of Site Visit and the Licensee acknowledges that this notice should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at http://ccld.ca.gov for child care updates, current forms, legislation and regulation information.



The following is cited per Title 22 Div. 12 of the CCR: See LIC 809-D pages.

SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Michelle Pascual
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 04/25/2022 08:40 AM - It Cannot Be Edited


Created By: Michelle Pascual On 04/22/2022 at 01:37 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: BEREZENKO, IRINA
FACILITY NUMBER: 343622895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(i)


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation LPA witnessed this when a child was sleeping in a swing, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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2
3
4
LPA explained that this violates safe sleep regulations. Facilty representative immediately removed the child and placed them in a pack in play.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:Roxana Saravia
LICENSING EVALUATOR NAME:Michelle Pascual
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document is an Amendment of Original Document on 04/25/2022 03:13 PM


Created By: Michelle Pascual On 04/22/2022 at 01:45 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: BEREZENKO, IRINA
FACILITY NUMBER: 343622895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.Based on observation and interview as well as record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA informed all facility representatives that the training needs to be renewed every two-years.
POC Due Date: 05/20/2022
Plan of Correction
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Licensee will ensure all staff renew their training and submit POC to LPA via e-mail by POC due date above
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Roxana Saravia
LICENSING EVALUATOR NAME:Michelle Pascual
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022


LIC809 (FAS) - (06/04)
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