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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625191
Report Date: 10/10/2023
Date Signed: 10/10/2023 10:28:41 AM

Document Has Been Signed on 10/10/2023 10:28 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:DYACHISHIN, ANNETTEFACILITY NUMBER:
343625191
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
10/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Annette DyachishinTIME COMPLETED:
10:45 AM
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On October 10, 2023 at approximately 08:45 AM, Licensing Program Analyst (LPA) Michelle Perez met with applicant Annette Dyachishin for the purpose of a pre-licensing inspection. Present in the home during the inspection was applicant's spouse. All individuals subject to criminal background review have obtained a criminal record clearance. Applicant plans to operate Monday through Friday from 8am to 5pm.

A health and safety inspection was conducted inside and out. This facility is a single story home. The house has four bedrooms, four bathrooms, laundry room, kitchen, garage, small office, pantry area and a room for the childcare a side and a backyard. Off-limit areas: The rear yard of the house, bedroom #3 with bathroom located inside, kitchen & living space surrounding kitchen, office, bathroom # 3, bedroom #2 off limits and Master bedroom/bathroom. Off-limits areas will remain inaccessible to children by closed doors and/or supervision. The children will have access to the childcare room through a separate entry, and have their own bathroom. Children will also have access to the side yard which is fenced. Applicant understands that licensing must be contacted if any on or off limit areas will change.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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: DYACHISHIN, ANNETTE
FACILITY NUMBER: 343625191
VISIT DATE: 10/10/2023
NARRATIVE
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Toxic and hazardous items are inaccessible to children and are stored in an area out of reach. Functioning smoke and carbon monoxide detectors and fire extinguisher were observed in the home. LPA received EMSA certified certificate for Preventative Health and Safety training, Applicant's pediatric CPR and First Aid training is valid until 07/2025. Mandated Reporter training expires 08/2025. Applicant stated there are weapons in the home. LPA observed proper storage of firearms. LPA observed a fireplace in the living room area which is barricaded. Supervision was discussed and applicant understands that children must be 100% supervised in unfenced areas. Immediate Civil Penalty regulations and deficiencies were reviewed. There are no bodies of water on the premises.

LPA consulted applicant regarding the following topics; new upcoming regulations, Type A vs. Type B deficiencies, complaints, LPA’s right to interview children without parental consent, civil penalties, incidental medical services, placement of detergents, placement of poisons, placement of medicines, announced vs. unannounced inspections, posting requirements, unusual incident reports, On-limits vs. Off-limit areas, licensing file management, fire drills, 100% supervision, fingerprint clearances, advertising, mandated reporting and best practices.



LPA consulted the applicant regarding personal rights. Applicant understands that corporal, physical and/or unusual forms of punishment is never allowed toward day care children or their own children during day care hours.
LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the Applicant can obtain updated licensing information, new regulations and access forms. LPA advised licensee of their responsibility to stay current regarding new regulations.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2023
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: DYACHISHIN, ANNETTE
FACILITY NUMBER: 343625191
VISIT DATE: 10/10/2023
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LPA advised Applicant to sign up for the quarterly updates provided by the Childcare Advocates Program. LPA provided the link https://www.cdss.ca.gov/inforesources/Community-Care-Licensing/subscribe for the Applicant to sign up for the updates.
LPA discussed the safe sleep regulations with applicant 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 applicant 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.

This facility does plan to provide Incidental Medical Services (IMS) if needed. 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. 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
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: DYACHISHIN, ANNETTE
FACILITY NUMBER: 343625191
VISIT DATE: 10/10/2023
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Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

LPA reviewed with applicant the LIC311D, Forms/Records To Keep in Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Applicant was encouraged to visit the department website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, self-assessment guides, regulations and legislation pertaining to family child care homes.
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important license related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2023
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: DYACHISHIN, ANNETTE
FACILITY NUMBER: 343625191
VISIT DATE: 10/10/2023
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Effective today 10/10/2023 this home is licensed for small family child care home.
Facility is approved for a small family childcare home licensed to serve a capacity of 6 children with no more than 3 infants or 4 infants only. Or with a capacity of 8 children: no more than 2 infants, 1 child in kindergarten or elementary school and 1 child at least age 6. Exit interview conducted.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5