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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500798
Report Date: 05/15/2025
Date Signed: 05/15/2025 01:36:34 PM

Document Has Been Signed on 05/15/2025 01:36 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:POLYNKO, ALYONAFACILITY NUMBER:
344500798
ADMINISTRATOR/
DIRECTOR:		ALYONA POLYNKOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 296-2942
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
05/15/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Alyona PolynkoTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 05/15/2025, Licensing Program Analyst Katy Velazquez (LPA) conducted a Case Management inspection to verify corrections from deficiencies cited on 04/08/2025. LPA arrived at the Family Child Care Home (FCCH) and was met by Licensee Alyona Polynko (L1). LPA disclosed the purpose of the inspection and was granted entrance into the FCCH. Also present in the FCCH was 1 adult Aide. LPA toured the facility and observed 3 infants and 5 preschool aged children being supervised by L1 and Aide. LPA determined, through accessing Guardian, that all required adults were background cleared and associated to the license. LPA utilized MultiLingual Technology translation services for today's inspection.

On 04/08/2025, the facility was cited 2 Type B deficiencies for a lack of complete children's files and complete adult files, including immunizations. The 1 deficiency was cleared during today's inspection for children's files. LPA provided L1 with a Proof of Correction letter. The staff files were not complete with immunizations. A civil penalty was assessed for failure to correct the staff file's with immunizations. The penalty will increase until LPA receives the required immunizations via email.

LPA observed 3 children in a sand box on the side of the FCCH in the OFF-limits side yard. The side yard had plastic netting to barricade the side of the house. A subsequent deficiency was cited on an 809-D page.

An exit interview was conducted, and the report was reviewed with Licensee Polynko. LPA provided Licensee Appeal Rights to L1. A Notice of Site visit was posted by LPA and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
NAME OF LICENSING PROGRAM MANAGER: Karyn Guerra
NAME OF LICENSING PROGRAM ANALYST: Katy Velazquez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2025
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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Document Has Been Signed on 05/15/2025 01:36 PM - It Cannot Be Edited


Created By: Katy Velazquez On 05/15/2025 at 01:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: POLYNKO, ALYONA
FACILITY NUMBER: 344500798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2025
Section Cited
CCR
102416.3(a)(6)

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Alterations to Existing Buildings or Grounds (a) Prior to making alterations... (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care...
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Licensee Polynko will install barriers on the side yards to replace the netting that is currently there. Licensee will email LPA photographs of the installation of barriers by 5:00 pm on 05/29/2025.
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This requirement was not met as evidenced by LPA observing children playing outside in the OFF-limits side yard of the FCCH. This poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karyn Guerra
NAME OF LICENSING PROGRAM MANAGER:
Katy Velazquez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025


LIC809 (FAS) - (06/04)
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