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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624973
Report Date: 07/06/2023
Date Signed: 07/06/2023 11:55:55 AM

Document Has Been Signed on 07/06/2023 11:55 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:TSYGANIUK, INNAFACILITY NUMBER:
343624973
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 9CENSUS: 5DATE:
07/06/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Inna TsyganiukTIME COMPLETED:
12:30 PM
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On July 6, 2023 at 11:30 AM, Licensing Program Analysts (LPAs) Tanya Washington and Pa Dao Vang met with Licensee Inna Tsyganiuk for an unannounced case management inspection to increase capacity to the maximum number of 14 children. During today's inspection LPAs observed Licensee and Staff #1 provide care and supervision to five children. Facility hours and days of operation are Monday- Friday, 24 hours. Licensee understands that care may not be provided to the same child for over 24 hours.

Licensee rents the home and a copy of the rental agreement has been previous submitted with the initial application. Applicant has obtained permission from the landlord to provide care up to 14 children, form LIC9149 has been signed and submitted with the initial application. LPAs discussed capacity options with and without an assistant and when the Licensee or an assistant are alone they divert to small license ratio requirements.

On June 26, 2023, Sacramento Metropolitan Fire Department granted a fire clearance.

The off limit areas in the home consist of entire second floor and garage. Licensee acknowledged that children may never enter the off-limit areas of the home.

Per Licensee there are no weapons on the premises. Infant safe sleep guidelines were discussed.

Licensee's CPR and First Aid is valid until 02/2025.

EFFECTIVE TODAY, 07/06/2023 THE FACILITY IS LICENSED TO SERVE A MAX. CAP OF 12 (WHEN THERE IS AN ASSISTANT PRESENT): WITH NO MORE THAN 4 INFANTS.
OR MAX CAP 14 - NO MORE THAN 3 INFANTS. 1 CHILD IN KINDERGARTEN OR ELEMENTARY SCHOOL AND 1 CHILD AT LEAST AGE 6. Notice of site visit posted and appeal rights were provided.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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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