343624944-8-7-2023-03-CC-KGUA-CUGTMH-20230807145109

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343624944
Report Date: 08/07/2023
Date Signed: 08/07/2023 02:51:15 PM

Document Has Been Signed on 08/07/2023 02:51 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:	SHAVELKOVA, ELENA		FACILITY NUMBER:	343624944
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	08/07/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Elena Shavelkova		TIME COMPLETED:	03:00 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	At 1:30 p.m. on Monday, August 7th, 2023, Licensing Program Analyst (LPA) Karyn Guerra met with Applicant, Elena Shavelkova, for the purpose of an announced, prelicensing change of location inspection. Facility is currently licensed at 343624526. Applicant understands that once licensed, previous facility will be closed and care cannot take place at that location. Applicant's spouse and adult daughter were also present. Daughter provided translation assistance in preferred language of Russian. Facility hours of operation are from 6:00 a.m. - 8:00 p.m., Monday thru Saturday. 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. Applicant guided LPA on a tour of the facility. The single story home consists of 3 bedrooms, 1 bathroom, kitchen, living room and backyard. There is an additional building behind the house with a laundry room, bathroom, and playroom. Off limits areas will consist of all bedrooms and laundry room. Applicant acknowledges that child care children must not enter these off limits areas of the home. LPA observed a 2A10-BC fire extinguisher and functioning smoke and carbon monoxide detectors. LPA reviewed the required postings. Cleaning materials, hazardous items, and medications are all stored inaccessible to children with magnet locks. Applicant stated that there are no weapons nor poisons in the home. LPA requested barricade for wood burning stove in living room. Report continued on 809-C.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

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 3

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: SHAVELKOVA, ELENA	FACILITY NUMBER: 343624944
	VISIT DATE: 08/07/2023

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
26
27
28
29
30
31
32

There is a pool in the backyard. LPA observed fencing surrounding the pool that is at least 5 feet tall. Gate was not self closing. Latch for gate was not within 6 inches from the top of the gate. There was tarp on part of the fencing that obstructed the pool from view. Top green portion of grated fencing is climbable and stretches. Back building was used as part of the pool fencing. The play room is located within the back building and has a window that leads to the pool. LPA reviewed civil penalties regarding bodies of water citations that can occur once the facility is licensed. Applicant understands that 100% supervision is required around bodies of water or in unfenced areas.

Applicant owns the home and provided proof of control of property via deed. Applicant has completed the required Preventative Health and Safety course. Applicant's current in person EMSA approved CPR and First Aid certification expires December, 2024. Applicant was reminded that CPR/First Aid certification shall be renewed every two years.
Applicant was reminded that once licensed they shall ensure that children are supervised at all times. Applicant understands that temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

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.

LPA reviewed requirements for assistants, and large FCCH ratio requirements. Applicant understands that if an assistant is not present, the Licensee shall adhere to small FCCH requirements.

report continued on 809-C.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: SHAVELKOVA, ELENA	FACILITY NUMBER: 343624944
	VISIT DATE: 08/07/2023

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
26
27
28
29
30
31
32

The following corrections are required prior to licensure:

1. Pool gate shall be self closing.

2. Latch on pool gate shall be within 6 inches of the top of the gate.

3. Tarp shall be removed from fencing so the pool view is not obstructed.

4. Top green portion of grated fencing shall not be climbable and shall keep its shape.

5. Fencing shall surround the pool so there is not access to the pool from any windows of the back building.

6. Wood burning stove shall be barricaded.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3