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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415587
Report Date: 03/06/2025
Date Signed: 03/06/2025 04:21:08 PM

Document Has Been Signed on 03/06/2025 04:21 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SHEVCHUK, ERENAFACILITY NUMBER:
434415587
ADMINISTRATOR/
DIRECTOR:		SHEVCHUK, ERENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 707-4101
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
03/06/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Erena ShevchukTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA), Jennifer “Jen” Beehler, met with Licensee, Erena Shevchuk, for an unannounced Annual/Random Inspection. LPA was granted access to the home by the Licensee and toured both indoors and outdoors during the inspection. Upon arrival, there were 6 children (4 preschool-age / 2 infants) and 2 staff (licensee/spouse) present, which is compliant with the home license capacity and ratio requirements. LPA observed all required postings near the entrance to the home. Hours of operation for the facility are Monday – Friday, 09:00 AM-04:00PM. There are no active waivers.

Licensee states that adults, over the age of 18, residing in the home are: herself, her spouse (Andriy), and her 2 sons and one daughter (2-school-aged/ 1 infant). All adults residing in the home have Criminal Background Check Clearance and signed Criminal Record Statements (LIC508).

Licensee was reminded that all adults 18 and over living or working in the home, 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.

LPA reviewed facility roster (LIC9040) and fire/disaster drill log during todays inspection. The last fire/disaster drill was conducted on 01/09/2025, which is compliant with the six month requirement for homes. LPA observed a fully charged 2A10BC fire extinguisher manufactured in 2019 that has not been serviced. This is not compliant with State Fire Marshal regulations. LPA reminded licensee that a fire extinguisher had to be replaced each year or serviced annually. LPA observed a fully functioning smoke detector and carbon monoxide detector.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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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Document Has Been Signed on 03/06/2025 04:21 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 03/06/2025 at 03:36 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SHEVCHUK, ERENA
FACILITY NUMBER: 434415587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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Licensee will update immunization records for children in care and provide LPA with photographic proof.
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
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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Licensee will create, update or complete LIC9227 for all children that have been enrolled in the facility under 12 months old. Licensee will provide photographic proof of completed LIC9227.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


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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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SHEVCHUK, ERENA
FACILITY NUMBER: 434415587
VISIT DATE: 03/06/2025
NARRATIVE
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Licensee states that she does currently have children in care who require Incidental Medical Services. LPA observed the medication to be contained separately in a cabinet out of reach of children. LPA discussed IMS regulations with licensee. This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. 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 are available at: https://www.ada.gov/resources/child-care-centers/.

Indoor areas of the home were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. Off-limits areas of the home (indoors): 2 bedrooms, family room, and master bathroom. There is one fireplace in the off limits area of the home, inaccessible from children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. Drinking water is readily available for children using cups. If a bottle is brought from the home it has the child's name on it. The bathroom in the home is clean, sanitary, and operable. The Licensee uses her cell phone as a working telephone in the facility. Stairs are barricaded appropriately to keep day care children safe. The backyard area of the home was inspected. LPA observed sufficient play equipment and supplies for the children that are in good condition and age-appropriate. Off-limit areas outside of home include: front yard. No outdoor bodies of water were observed during today's inspection.

Infant Safe Sleep regulations (PIN 20-24-CCP) was discussed with the Licensee, including the Individual Infant Sleeping Plan (LIC9227). LPA reminded Licensee that infants up to 12 months of age should be placed on their back to sleep, that cribs should be free of all loose articles and hanging objects, and that infants should not be swaddled. Infants should be supervised while sleeping and documentation of sleep checks every 15 minutes should remain in the infant’s file. Documentation should include the time of the check, the infant’s physical condition, and initials of the staff member checking on the infant. LPA observed infants' sleep logs complete for all infants.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SHEVCHUK, ERENA
FACILITY NUMBER: 434415587
VISIT DATE: 03/06/2025
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More information can be found at the Child Care Licensing Safe Sleep webpage athttps://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.

5 children’s files were reviewed during today's inspection for the following documents: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Immunization Records (PM286), Individual Infant Sleep Plan (LIC9227) and sleep check documentation. LPA observed 3/5 records missing up to date immunization records. LPA observed 2/3 children who were enrolled younger than 12 months were missing LIC9227.

1 staff file (licensee) were reviewed for the following documents: Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), Mandated Reporter Training Certificate, and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). There is at least one staff member present with current CPR/First-Aid that expires 08/24/2026. The Licensee has current Mandated Reporter Training that expires on 08/13/2026 and LPA reminded licensee that training must be renewed by all staff every 2 years.

Supervision of children was discussed with the Licensee and she understands that she must be home during day care hours and ensure that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

As a result of today's inspection, 2 Type B deficiencies were cited, more details provided in the attached LIC809-D. Exit interview conducted with Licensee, Erena Shevchuk, report reviewed and provided along with appeals rights.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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