<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415925
Report Date: 11/04/2022
Date Signed: 11/04/2022 10:15:47 AM

Document Has Been Signed on 11/04/2022 10:15 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: 5CENSUS: 4DATE:
11/04/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Tatyana MumzhuTIME COMPLETED:
10:30 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
Licensing Program Analyst (LPA), Janette Cruz, conducted a case management inspection in response to Licensee's request to increase the capacity from 8 to 14 children. LPA met with Tatyana Mumzhu, Licensee. LPA observed three infants and one preschool child present in the home. LPA also observed Tatyana's spouse, Denis Golubev and Tatyana's mother-in-law, Nina Golubeva, present in the home. There are three adults residing in the home: Licensee, Licensee’s spouse and mother-in-law. Licensee stated that Nina Golubeva will be her adult assistant in the daycare. The daycare is open Monday thru Friday from 8:00 AM to 6:00 PM. Licensee has current CPR/First Aid certifications and Mandated Reporter Training certificates on file. Both indoor and outdoor areas of the home were inspected.

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, one bathroom and garage. Off limit area outside of the home - gated left side of the yard.

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 (2 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 with Licensee. 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
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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 2
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: 11/04/2022
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
LPA obtained a copy of children's roster. LPA reviewed staff and children's files.
A review of staff records during today's inspection indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

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-carelicensing/public-information-and-resources/safesleep 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.

LPA reviewed with the 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.

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.

Fire clearance was granted on October 24, 2022. Licensee was advised that the following items need to be completed prior to approval of a large Family Child Care Home license:
1. Mandated Reporter Training Certificate for adult assistant : Nina Golubeva
2. Updated lease agreement that states Nina Golubeva is included as tenant/residing in the home
3. Review and approval by LPA's Manager

Exit interview was conducted with Tatyana Mumzhu, Licensee. No deficiency was cited during today's inspection.

A Notice of Site Visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2