434415587-2-15-2023-07-CC-KMEO-CP3VCP-20230215151929

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415587
Report Date: 02/15/2023
Date Signed: 02/15/2023 03:19:40 PM

Document Has Been Signed on 02/15/2023 03:19 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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	SHEVCHUK, ERENA		FACILITY NUMBER:	434415587
ADMINISTRATOR:	SHEVCHUK, ERENA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 707-4101
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	14	CENSUS: 9	DATE:	02/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Erena Shevchuk		TIME COMPLETED:	03:30 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 February 15th, 2023 at 2:10pm, Licensing Program Analyst (LPA) Kassandra Medrano conducted an annual required inspection which included a toured the home and yard, and a review of the required day-care forms with the licensee today. Present in the home is Licensee, 9 children and 1 helper, Deborah Hassy. Licensee has two minor children who were both present as well. Capacity and ratio requirements of children were observed in compliance today. This type of home is a single family home. Adults living in the home are Licensee, and husband. A review of records indicates that all adults working or living in the home who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, 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. The day-care operates Monday- Friday, 9am-4pm. Licensee has day-care insurance through: Acord. LPA observed the following: Day-care area is clean, orderly, and equipped with age-appropriate toys and equipment for the children. No baby walkers, bouncers, exercausers, etc. allowed to be used during day-care hours. Home has proper lighting and ventilation. Home has a working telephone, a working smoke and carbon monoxide detector, and a fully charged 2A10BC fire extinguisher. Licensee states there are no bodies of water on the property. There is in the day-care area. There are no detergents, or cleaning products accessible to day-care children. Poisons are locked. Licensee states there are no guns or weapons of any kind in the home. The yard is fenced. Licensee’s CPR and First Aid expires 4/2024. Emergency drills are conducted at least once every six months and properly logged, 1/11/2023. Licensee provides daily snacks and meals, parents are required to bring their infants formula. Isolation of sick children reviewed/discussed. Children’s roster was reviewed and is complete and up to date. Staff/helper files were reviewed and are complete. During review of children's files it was observed that files were missing sleeping logs, as well as LIC 9227. Supervision and transportation of children was discussed. Capacity options were reviewed. Licensee understands that care cannot be provided for more than the capacity as stated on the license.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SHEVCHUK, ERENA	FACILITY NUMBER: 434415587
	VISIT DATE: 02/15/2023

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
26
27
28
29
30
31
32

Requirements for reporting suspected child abuse was discussed, as well as reporting requirements for unusual incidences. All required postings are properly posted (License/Parent’s Rights poster/Emergency Disaster Plan and Earthquake Preparedness Checklist)
Licensee has updated immunizations. Licensee was reminded that as of September 1, 2016, a person may
not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza,
pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and
1597.662. Licensee was informed about the Provider Information Notices (PINs) on CCLD website. Licensee
was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or
www.mandatedreporterca.com). 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. This report and appeal rights were discussed with Licensee. This report must be available in the
facility for public review. To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.
Notice of Site Visit was given and must remain posted for 30 days.
California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):
Exit interview conducted and report was reviewed with the licensee, Erena.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/15/2023 03:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SHEVCHUK, ERENA	FACILITY NUMBER: 434415587
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 infants were missing lic 9227 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/15/2023
	Plan of Correction
1 2 3 4	Licensee stated that she will send completion of document via email

Type B

Section Cited

CCR

102425(j)(2)(D)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/15/2023
	Plan of Correction
1 2 3 4	Licensee stated that she will send completion of logs via email

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3