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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500798
Report Date: 03/03/2023
Date Signed: 08/13/2024 03:41:47 PM

Document Has Been Signed on 08/13/2024 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 S. CC RO, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:POLYNKO, ALYONAFACILITY NUMBER:
344500798
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
03/03/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Alyona PolynkoTIME COMPLETED:
03:00 PM
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On 03/03/2022, Licensing Program Analyst Katy Maestas (LPA) met with Applicant Alyona Polynko (A1) for the purpose of a pre-licensing inspection. LPA disclosed the purpose of the inspection and was granted entrance into the Family Childcare Home (FCCH). LPA provided the Entrance Checklist to A1. Also present in the FCCH was A1's 2 minor children. A1’s primary language is Russian; translation was not necessary. All individuals subject to criminal background review have obtained a criminal record clearance verified by LPA accessing Guardian. A1’s tentative hours of care are Monday through Friday, from 8:00 AM until 6:00 PM. A1 does not intend on providing overnight or weekend care.

A health and safety inspection was conducted inside and outside of the FCCH. A1 accompanied LPA for the entirety of the tour. The FCCH is a two-story house. Downstairs consists of: kitchen, dining room, living room, bedroom, bathroom, family room, laundry room, and access to the garage. The upstairs consists of: master bedroom and bathroom, 3 bedrooms, bathroom, and loft. LPA verified that toxic and hazardous items were inaccessible to children in care. LPA observed stairs that require a baby-gate to barricade the stairway from children in care. LPA observed a fireplace in the living room that is barricaded by glass; A1 stated that the fireplace will not be used during childcare hours. The outdoor play area was toured which includes the backyard. LPA observed that a substantial portion of the fence surrounding the backyard is down and the yard is not enclosed. LPA measured the fence surrounding the pool and it is not the required 5 feet in height. A1 stated that 1 cat reside in the FCCH. The OFF-limits areas of the FCCH are the garage, laundry room, closet (near the stairway), entire 2nd floor, side yards, and pool pump enclosure. A1 understands that OFF-limits areas must remain inaccessible to children in care.

A functioning smoke detector and carbon monoxide detector was observed and tested in the living room. LPA observed cleaners stored in the kitchen and bathroom cabinets that have safety locks on the doors. A 2A10BC fire extinguisher and first-aid kit was observed off the kitchen. A1 stated there are no firearms nor weapons in the home.


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SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2023
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: POLYNKO, ALYONA
FACILITY NUMBER: 344500798
VISIT DATE: 03/03/2023
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LPA discussed Mandated Reporter Training with A1. Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their Mandated Reporter duties and to renew their training every 2 years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/. The training is currently provided in English and Spanish. A1 has a current Mandated Reporter Training Certificate which will expire on 12/13/2024. Current Pediatric CPR and First Aid training was verified for A1 and expires on 12/14/2024. Completion of Preventative Health and Safety training, including nutrition and lead exposure, was verified before the inspection. Proof of required immunizations for A1 was also verified before the inspection.

LPA discussed the Safe Sleep Regulations with A1 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 A1 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. LPA discussed the requirement to check and log infant napping every 15 minutes for infants under 24 months old. LPA provided a copy of the LIC 9227/Individual Sleeping Plan to be completed for infants under 12 months old.

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS: 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)/ (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.

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SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: POLYNKO, ALYONA
FACILITY NUMBER: 344500798
VISIT DATE: 03/03/2023
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To receive important licensed related information, 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.

A1 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.

A1 understands that licenses are not transferable, and once licensed, Licensee must live in the home and be present for 80% of the operating hours. A1 understands that if an unusual incident occurs; Licensing is to be notified via phone call, e-mail or fax within 24 hours and the LIC 624/ Unusual Incident Report shall be submitted within 7 days to remain in compliance. A1 understands that if any structural changes are made to the FCCH; Licensing must be notified PRIOR to construction.



A1 understands that if she wants to make any OFF-limits area an ON-limits area, she must notify Licensing and LPA must do an inspection BEFORE children are allowed in said area. A1 understands that children’s and staff’s records are to be maintained according to Title 22 regulations and be accessible to Licensing for up to 3 years. LPA reviewed with Licensee 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. A1 understands that fire drills must be conducted and documented once every 6 months.

Once the following items are corrected, A1 will be approved for a Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.


LPA will grant license once proof of corrections are submitted to the Department:
1. Child Safety Lock on the sliding glass door in the downstairs bedroom (used for day care)
2. Installed baby-gate to barricade the stair way
3. Fence enclosing the back-yard
4. Fence enclosing the pool that meets Title 22 Regulations
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SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: POLYNKO, ALYONA
FACILITY NUMBER: 344500798
VISIT DATE: 03/03/2023
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An exit interview was conducted, and the report was reviewed with A1. LPA provided A1 with Licensee Appeal Rights.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC809 (FAS) - (06/04)
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