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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625778
Report Date: 05/23/2024
Date Signed: 05/23/2024 09:44:58 AM

Document Has Been Signed on 05/23/2024 09:44 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:DERYABKINA, VALERIYAFACILITY NUMBER:
343625778
ADMINISTRATOR/
DIRECTOR:		DERYABKINA, VALERIYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 335-8117
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/23/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Valeriya DeryabkinaTIME VISIT/
INSPECTION COMPLETED:
09:50 AM
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On Thursday, May 23, 2024, at 8:30 AM, Licensing Program Analysts (LPAs) Tanya Washington and Lea Habtom met with Applicant Valeriya Deryabkina for a second announced pre-licensing inspection. Upon arrival there were no children present in the home. At around 9:25 AM, Gleb Efimenko arrived to the facility and allowed LPAs to tour the area of the home which was previously undisclosed. Gleb rents a portion of the home which has a separate laundry room, kitchen, three bedrooms and two bathrooms. The two living spaces is separated by a door with a lock on the side of Gleb's residents. LPA notified applicant to keep the door closed and or locked when children are present.

Both Gleb and Valeriya have obtained the required fingerprint clearances and are associated to the facility.

Off limit areas of the home will consist of: master bedroom (Applicant's room), three car garage, Gleb's part of the home (left side of the home) and part of the yard directly behind the home. Refer to facility sketch on file. The Applicant acknowledged that children may never enter these off-limit areas. Off-limit areas will remain inaccessible to children by closed door and/or supervision.

Applicant agrees to report any changes made to on and off limit areas of then facility.

Applicant was advised that a fire inspection is required of the entire facility prior to licensure. Fire Department will be reaching out to her to schedule an inspection.

UPON RECEIPT OF FIRE CLEARANCE FACILITY WILL BE GRANTED A LICENSE 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.

SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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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