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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343626378
Report Date: 12/23/2024
Date Signed: 12/23/2024 02:11:28 PM

Document Has Been Signed on 12/23/2024 02:11 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:DZIUBA, ELVIRAFACILITY NUMBER:
343626378
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
12/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Elvira DziubaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 12/23/2024, Licensing Program Analyst (LPA) Josiah Gathing met with Elvira Dziuba for a case management inspection to follow up on a previous pre-licensing inspection. The purpose of today's visit was to verify that the swimming pool area is now surrounded by fencing at least five feet high. LPA confirmed during today's inspection that the fence height has now been increased to five feet. LPA will approve the license as of 12/23/2024. LPA also assisted in associating several additional adults to the facility through the Guardian background check portal during today's inspection.

LPA printed and provided a copy of this report.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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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