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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624944
Report Date: 08/15/2023
Date Signed: 08/15/2023 09:30:27 AM

Document Has Been Signed on 08/15/2023 09:30 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SHAVELKOVA, ELENAFACILITY NUMBER:
343624944
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/15/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Elena ShavelkovaTIME COMPLETED:
09:40 AM
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On August 15, 2023 at 9:00 AM, Licensing Program Analyst (LPA) Tanya Washington and Licensing Program Manager (LPM) Amanda Blesi met with Applicant Elena Shavelkova for a scheduled follow up pre-licensing inspection to ensure the pool fencing is in compliance with Title 22 Regulations.

Applicant and her daughter accompanied licensing staff on a tour of the home. Licensing Staff observed that the pool is fully enclosed by a fence. There is a gate that self closes, self latches and swings away from the pool. Applicant was reminded to not place any items near the fence to prevent children from climbing over.

Effective today. 08/15/2023, the facility is licensed for a maximum of 6 children - no more than three infants or four infants only or 8 children no more than two infants and one child at least age 6 and one child enrolled and attending pre-kindergarten or elementary school. LANDLORD CONSENT IS REQUIRED IN ORDER TO ACCEPT 7th and 8th CHILD.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
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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