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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343627023
Report Date: 06/04/2025
Date Signed: 06/04/2025 02:00:15 PM

Document Has Been Signed on 06/04/2025 02:00 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:PYSARENKO, HANNAFACILITY NUMBER:
343627023
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 3CENSUS: 3DATE:
06/04/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Hanna PysarenkoTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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This is a Change of Location from previous facility number 343625721.
On Wednesday, June 4, 2025, Licensing Program Analyst (LPA) Tanya Washington conducted a Change of Location inspection and met with Applicant, Hanna Pysarenko. Upon arrival Applicant's spouse Serhii Pysarenko and two minor related children were also present in the home. LPA conducted a health and safety inspection of the facility inside and out. Facility hours of operation will be Monday through Friday, 7:30 AM – 6:00 PM.

Applicant rents this home and copy of the rental agreement was provided with the application. Because the applicant rents the home, proof of landlord notification is required. Applicant submitted signed form LIC9151 confirming that the landlord was verbally informed that childcare will be provided. Applicant is in the process of obtaining a signed landlord consent. Applicant requested to be licensed for six children and plans to submit a capacity increase for a large license in next few days.

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.

This facility is a two story home. The first floor has a living room, kitchen, family room, laundry room and a garage which the Applicant plans to use for children. The second floor has four bedrooms and two bathrooms. There is a fully fenced backyard with a small dwelling unit which the applicant plans to use for storage purposes. Off limit areas of the facility will include: entire second floor and detached dwelling utilized for storage in the backyard. Applicant stated she understands that children may not enter off limits areas and any changes made must be cleared through Licensing.

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Amanda Blesi
NAME OF LICENSING PROGRAM ANALYST: Tanya Washington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: PYSARENKO, HANNA
FACILITY NUMBER: 343627023
VISIT DATE: 06/04/2025
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Chemicals, knives, medications, and hazardous items are all stored in a way that is inaccessible to children. LPA advised that poisonous items must be key or combination locked. LPA observed the smoke and carbon monoxide detector are functioning properly. LPA observed a 2A-10-BC fire extinguisher. Applicant stated there are no firearms in the home and LPA did not observe any bodies of water on the premises. There is a gas fireplace located in the family room of the facility which is properly barricaded and Applicant stated that it will not be used during day-care hours. Applicant stated she understands that her own children under the age of 10 count as part of the ratio.

LPA discussed with Applicant the safe sleep regulations and the Child Care Licensing Safe Sleep web page 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 items.

Incidental Medical Services- IMS policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.

LPA provided the Department’s website WWW.CCLD.CA.GOV, so the Applicant can obtain updated licensing information, new regulations and access forms. LPA advised Applicant of their responsibility to stay current by reviewing PINs on the website.

Effective today, 06/04/2025, the new facility is licensed to operate as a Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only. Infants are children under the age of 2 years.
NAME OF LICENSING PROGRAM MANAGER: Amanda Blesi
NAME OF LICENSING PROGRAM ANALYST: Tanya Washington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC809 (FAS) - (06/04)
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