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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625641
Report Date: 04/23/2024
Date Signed: 04/23/2024 03:41:05 PM

Document Has Been Signed on 04/23/2024 03:41 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:TSYGANIUK, ROMANFACILITY NUMBER:
343625641
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
04/23/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Roman TsyganiukTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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On Tuesday, April 23, 2024 at 12:05 PM, Licensing Program Analysts (LPA) Tanya Washington and Office Technician (OT) Yvonne Flores met with applicant, Roman Tsyganiuk for the purpose of a pre-licensing inspection. There were no children present during today's inspection. All individuals subject to criminal background review have obtained a criminal record clearance. Applicant plans to operate Monday-Friday, 24 hours a day. Applicant understands that care may not exceed 24 hour period for the same child.
Applicant's spouse owns the property and control of ownership was submitted for verification.

A health and safety inspection were conducted inside and out. This facility is single story which has four bedrooms, two bathrooms, living room, dining room, kitchen, detached garage, fenced front yard and fenced backyard. The off-limit areas of the home will be two bedrooms closest to the children's bathroom, office room with an attached bathroom, detached garage and backyard. Off-limit areas will remain inaccessible to children by closed doors and/or supervision. Toxic and hazardous items are inaccessible to children. Functioning smoke and carbon monoxide detectors were observed in the home. Applicant has a full 2A10BC fire extinguisher. Preventative Health, current pediatric CPR and first aid training was verified and expires 02/2026. Applicant stated that there are no weapons in the home. The fireplace located in the living room is properly barricaded. Supervision was discussed and applicant understands that children must be 100% supervised in unfenced yards and around bodies of water.
During the tour of the backyard, LPA observed an empty spa which does not have a cover as required per Title 22 Regulations. Immediate Civil Penalty regulation and deficiencies were reviewed.

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, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.
Report continued on LIC809C
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
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: TSYGANIUK, ROMAN
FACILITY NUMBER: 343625641
VISIT DATE: 04/23/2024
NARRATIVE
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LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

LPA consulted applicant regarding the following topics; 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, 80% supervision, 100% supervision, fingerprint clearances, advertising, mandated reporting best practices, and applicant’s responsibility to stay up to date on new law and regulations. Applicant is also advised that temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

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 website www.ccld.ca.gov, so the applicant can obtain updated licensing information, new regulations and access forms. LPAs advised applicant of their responsibility to stay current regarding new regulations.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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) or (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.

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 licensed-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.

Continued on LIC809C
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
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: TSYGANIUK, ROMAN
FACILITY NUMBER: 343625641
VISIT DATE: 04/23/2024
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LPAs 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. LPAs 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.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Applicant must comply with the following prior to becoming licensed:
- Remove spa from the premises or install appropriate cover with latches
- Post PUB394, LIC610A and LIC9148
- Written agreement between Roman and Inna Tsyganiuk which will allow Roman to operate a childcare
- Signed LIC9151
- Signed LIC9149

After correction/completion of above items this facility will be granted a childcare home license 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 and report was reviewed with applicant Roman Tsyganiuk.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC809 (FAS) - (06/04)
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