414005179-11-12-2024-05-CC-MZAA-DAXVXX-20241112155015

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414005179
Report Date: 11/12/2024
Date Signed: 11/12/2024 03:50:23 PM

Document Has Been Signed on 11/12/2024 03:50 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	VASYLYSHYN, LYUDMYLA		FACILITY NUMBER:	414005179
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	11/12/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:10 PM
MET WITH:	Applicant, Lyudmyla Vasylshyn		TIME VISIT/ INSPECTION COMPLETED:	04:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On November 11, 2024 at approximately 1:10pm, Licensing Program Analyst (LPA) Melissa Zaragoza conducted a scheduled, pre-licensing inspection. LPA met with applicant, Lyudmyla Vasylyshyn, and explained the purpose of the inspection. Present during LPA's visit included applicant's adult daughter. All adults living in the home have fingerprint clearance on file. Applicant submitted an application for a family child care home license on November 5, 2024. Applicant lives in a two-level home with their adult daughter. Applicant plans to operate Monday through Friday 7:30am to 5:30pm. Applicant plans to care for children ages 12 months to school age. Applicant is aware children living in the home under 10 years old, are counted towards overall capacity. With applicant, LPA inspected the entire home, inside and outside, for health and safety hazards. The home is a two level home that consists of 4 bedrooms, 3 bathrooms, living room, kitchen, deck, backyard, laundry room, and garage. The DAY CARE AREAS located on the first level of the home. Day care areas are the stairs for walking down, bathroom #1, playroom #1, playroom #2, bedroom #1(napping room), backyard for walk through only, and side yard. The OFF LIMIT AREAS are the entire second floor of the home, bedroom #2, bedroom #3, bedroom #4, kitchen, living room, bathroom #2, bathroom #3, garage, and laundry room. Off limit areas are made inaccessible with child safety door handles and child safety gates. LPA observed stairs to the home to have a child safety gate installed. LPA observed the day care area to be clean and safe. Home is equipped with a fully charged fire extinguisher that was observed to be secured to wall located near stairs. Home is equipped with multiple smoke detectors. During visit, LPA tested a smoke detector and carbon monoxide detector that was observed to be working. Day care areas were observed to be equipped with a variety of toys, materials and furniture that were age appropriate. LPA observed electrical outlets to be made inaccessible with safety covers. (Continue Report on Page 2...)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VASYLYSHYN, LYUDMYLA	FACILITY NUMBER: 414005179
	VISIT DATE: 11/12/2024

NARRATIVE

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Kitchen in playroom #2 was observed to be clean and safe. Cabinets and drawers were also observed to not have anything that can be a risk to children in care. Knives and sharp objects are made inaccessible. Bathrooms were observed to be in proper working condition. LPA observed a trash can to have a tight fitted lid. Bathroom is equipped with age-appropriate toileting equipment and sanitation products.

The backyard area is entirely enclosed and fenced. LPA observed backyard to have a variety of toys and equipment that were age appropriate. LPA did not observe any pools, spas or bodies of water on site.

Applicant was reminded baby walkers, bouncers, jumpers and any other similar items are not to be used for children in care. LPA reminded applicant emergency disaster drills are to be conducted and documented at least once every six months.

Applicant's discipline policy will be to wait for the child to calm down and communicating with child. The designated isolation area will be in bedroom #1 (napping room), separate from other children in care. LPA reminded applicant; children must be supervised at all times. Applicant plans to provide a food service that includes breakfast, lunch, dinner, and snacks. Food preparation, sanitization, children's allergies was discussed.

Applicant's CPR/First Aid training is current and will expire 10/06/26. Applicant's Mandated Reporter training certification is also current and will expire 10/30/26. LPA reminded applicant CPR/First Aid training and Mandated Reporter training must be renewed every two years. Applicant was also reminded Mandated Reporter training must be renewed every two years by all staff working with children. Applicant has proof of required immunizations (MMR, Tdap and Flu) that were provided to LPA. Per applicant, there are no weapons or firearms in the home.

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, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.
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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VASYLYSHYN, LYUDMYLA	FACILITY NUMBER: 414005179
	VISIT DATE: 11/12/2024

NARRATIVE

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The applicant provided proof of control of property. Because the applicant rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

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) or (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 reviewed with applicant 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 applicant.

LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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 equipment.

On this date, 11/05/24, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VASYLYSHYN, LYUDMYLA	FACILITY NUMBER: 414005179
	VISIT DATE: 11/12/2024

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Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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 platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website athttps://www.cdss.ca.gov/inforesources/community-carelicensing/ subscribe and select the Child Care option to receive email communication.

As of todays, date 11/12/2024, the applicant has been approved for a family childcare home license.

Exit interview conducted and report was reviewed with the applicant, Lyudmyla Vasylyshyn.

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024

LIC809 (FAS) - (06/04)

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