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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004950
Report Date: 09/20/2022
Date Signed: 09/20/2022 01:48:14 PM

Document Has Been Signed on 09/20/2022 01:48 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ZHAMBALOVA, LILIAFACILITY NUMBER:
414004950
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
09/20/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lilia ZhamTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Marie Rodriguez conducted a scheduled pre-licensing inspection and met with Licensee Lilia Zhambalova. Licensee has relocated from facility #414004792 to this location. Home is a single story house with four bedrooms and two bathrooms. Licensee rents home and lives here with her husband and mother.

LPA and Licensee inspected entire home for health and safety hazards. Daycare Areas: Living room, dining room, bedroom #3 (nap room), bathroom #2, and portion of the backyard with an overhead awning for shade. Off Limit Areas: Kitchen, bedroom #1, bedroom #2, bedroom #4, bathroom #1, garage, and fenced off portion of the backyard. Licensee may use bedroom #1 as a nap room and the fenced off portion of the backyard in the future. Licensee will let LPA know of any changes made to the facility sketch. All off limit areas, including all closets are properly barricaded. Home is clean and orderly with sufficient lighting and ventilation. Home has age appropriate toys and equipment available for children in care. Play structure in the backyard has sufficient padding underneath. Home has a working smoke and carbon monoxide detector, a working telephone, and a fully charged fire extinguisher. First aid kit is fully stocked and accessible. There are no pools, spas, or bodies of water on the property. All cleaning supplies, poisons, and other chemicals are stored inaccessible to children. All harmful and sharp objects are made inaccessible from children in care. Licensee states there are no guns or weapons in the home.

Licensee states she will conduct an emergency drill once every six months and will log drills. Licensee states discipline policy is redirection. Licensee's First Aid/CPR certificate expires in April 2023. Postings will be posted by the front door. The Licensee is reminded of NO walker, exersaucers, jumpers, bouncers and any similar items to be used for children in care and shall be made inaccessible.

Capacity limits of a Small and Large License were discussed with Licensee. Licensee is reminded that when operating at a Large capacity, there must be a Helper present.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ZHAMBALOVA, LILIA
FACILITY NUMBER: 414004950
VISIT DATE: 09/20/2022
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Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years by all staff hired. Training can be taken online at www.mandatedreporterca.com. If training is not available in native language, a statement can be written stating exemption until the translation is available.

Fire clearance inspection was conducted on September 16, 2022. A follow up inspection will be conducted on September 23, 2022 after fire alarm system has been installed.

Small Family Child Care License has been approved and is effective as of today, September 20, 2022.A Large Family Child Care License will be approved once fire clearance has been granted.

Licensee 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.

LPA discussed the safe sleep regulations with licensee 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 licensee 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.

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
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ZHAMBALOVA, LILIA
FACILITY NUMBER: 414004950
VISIT DATE: 09/20/2022
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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

Entrance Checklist was provided to the licensee.

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.

To receive important licensed-related information to licensed facilities, 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.

Exit interview conducted and report was reviewed with the licensee Lilia Zhambalova.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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