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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415925
Report Date: 05/25/2022
Date Signed: 05/25/2022 10:49:54 AM

Document Has Been Signed on 05/25/2022 10:49 AM - 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MUMZHU, TATYANAFACILITY NUMBER:
434415925
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 6CENSUS: 4DATE:
05/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Tatyana MumzhuTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Janette Cruz met with Tatyana, Mumzhu, Licensee, for an unannounced Required 1-year annual inspection. LPA was granted access to the home by the Licensee. LPA also observed Licensee's spouse, Denis Golubev and four preschool day care children present in the home during today's inspection. The Licensee was operating within her capacity and ratio requirements. LPA observed the required postings, including the facility license, posted inside the home. Days and hours of operation are Monday - Friday from 8:00 AM to 6:00 PM. Licensee and her spouse are the adults residing in the home. All adults have clearances for Tuberculosis and Criminal Background/Child Abuse Index clearances. There are no active waivers for this facility.

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 02/18/2022. Licensee does not have an active Child Care Liability Insurance. Licensee has the required vaccinations (MMR, Tdap, & flu opt-out). LPA reviewed Licensee's Mandated Reporter Training for Child Care Workers and Licensee's Pediatric First Aid & CPR Training certifications. LPA reviewed six children's files which were complete with the required forms.

LPA discussed the safe sleep regulations with the 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 the 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.

LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MUMZHU, TATYANA
FACILITY NUMBER: 434415925
VISIT DATE: 05/25/2022
NARRATIVE
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`equipment for the day care children. Licensee states that a child will be isolated in the living room area of the home if necessary due to illness or communicable disease.

LPA observed the home is clean, orderly, and safe for the day care children. LPA also observed a screened fireplace. There are no open face heater units and stairs inside the home. Off limit areas in the home: two bedrooms and one bathroom.

LPA observed a fully charged 2A10BC fire extinguisher, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. Licensee stated she does not have any weapons in the home. Licensee states that she has pets (3 rabbits) in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Licensee stated that all poisons are stored at the garage. The Licensee states that she does not administer medication to the day care children.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

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.

Supervision of children was discussed with Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MUMZHU, TATYANA
FACILITY NUMBER: 434415925
VISIT DATE: 05/25/2022
NARRATIVE
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understands that she cannot have more than eight children in the home at any time without a fully qualified adult present. Licensee states that she does not transport any day care children. The Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

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/process.

LPA provided Licensee with website resources on managing food allergies at school and handling medical emergencies related to food allergies.

CDC Managing Food Allergies at School
https://www.cdc.gov/healthyschools/foodallergies/index.htm

American Academy of Pediatrics Healthy Children Medical Emergencies
https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/When-to-Call-Emergency-Medical-Services-EMS.aspx

Exit interview conducted and report was reviewed with the Licensee, Tatyana Mumzhu. Deficiencies were issued during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
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Document Has Been Signed on 05/25/2022 10:49 AM - It Cannot Be Edited


Created By: Janette Cruz On 05/25/2022 at 10:12 AM
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: MUMZHU, TATYANA
FACILITY NUMBER: 434415925

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record reviews, the licensee did not comply with the section cited above. Licensee did not renew her Mandated Reporter Training Certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2022
Plan of Correction
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Licensee will submit to LPA a current Mandated Reporter Training Certificate by POC date 06/24/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Diana Stephenson
LICENSING EVALUATOR NAME:Janette Cruz
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022


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Document Has Been Signed on 05/25/2022 10:49 AM - It Cannot Be Edited


Created By: Janette Cruz On 05/25/2022 at 10:28 AM
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: MUMZHU, TATYANA
FACILITY NUMBER: 434415925

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee did not renew her Pediatric First aid and cardiopulmonary resuscitation (CPR) training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2022
Plan of Correction
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Licensee will submit to LPA a current Pediatric and CPR training certificate by POC date 06/24/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Diana Stephenson
LICENSING EVALUATOR NAME:Janette Cruz
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022


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