434415925-1-22-2025-07-CC-AYAG-DD6V9B-20250122151405

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415925
Report Date: 01/22/2025
Date Signed: 01/22/2025 03:14:39 PM

Document Has Been Signed on 01/22/2025 03:14 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:	MUMZHU, TATYANA		FACILITY NUMBER:	434415925
ADMINISTRATOR/ DIRECTOR:	TATYANA MUMZHU		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 839-1465
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	01/22/2025
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:25 PM
MET WITH:	Tatyana Mumzhu		TIME VISIT/ INSPECTION 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	At 12:25 PM, Licensing Program Analyst (LPA) Andy Yang met with Licensee, Tatyana Mumzhu to conduct an announced inspection initiated by Licensee. The purpose of today's inspection is to place the license to active status as it is currently in an inactive status placed by the licensee. The license has been inactive from 6/05/2024 to 02/01/2025. Licensee is currently licensed for Large Family Child Care Home (FCCH). Present for this inspection were Licensee (2) Adults (husband & mother), and (1) infant (son). Licensee and her husband & mother are the only adults living in the home. All adults have criminal clearance and TB test. The home was toured to conduct a Health and Safety Inspection. Days and hours of operation will be from Monday to Friday 8:00 AM to 6:00 PM. The ages of the children to be served will be from 6 months to 5 years old. Licensee has provided updated LIC 279 indicating the updated age range to be served. The home is a single family home. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are living room, kitchen, (2) bedrooms (bedroom closest to the entrance, and bedroom at the end left side), bathroom, dining room (living room), and backyard. The OFF LIMIT AREAS are garage, master bedroom, and master bathroom which will be inaccessible by closed and/or locked doors and visual supervision. The ISOLATION AREA will be the dining room. The outdoor play area is free from defects or dangerous conditions and is fenced. LPA observed a fire place which is barricaded by a glass door and is locked by a locking mechanism. There are ample age-appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs, or any other bodies of water. All hazardous materials and toxins are kept out of the reach of children, and it was observed that there are no toxins or hazardous items accessible today. Licensee states that any poisons are stored in garage which is OFF LIMITS. LPA reminded Licensee that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes. * Continue Page 2*

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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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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: MUMZHU, TATYANA	FACILITY NUMBER: 434415925
	VISIT DATE: 01/22/2025

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The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The Licensee's CPR and First Aid certificate expired on 5/2024. Licensee has made an appointment for the 1st aid/CPR training on February 9, 2025. Licensee completed the Mandated Reporter Training for Child Care Providers on 1/22/2025 (expires on 1/2027) and a copy of the certification is on file. Licensee was reminded of Mandated reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. A copy of the Licensee’s immunization is on file. Per Licensee, there are no firearms in the home.

Licensee states that she will not administer any medication to the children at this time. Licensee states that a child will be isolated in the ISOLATED AREA if necessary due to illness or communicable disease. Licensee has a First Aid kit with a touchless thermometer in the home. Also discussed with Licensee the requirements for reporting suspected child abuse, unusual incidents/injuries, and heat related illnesses.

Forms of discipline to be used by Licensee are talking and redirecting. Licensee understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, children are treated with dignity, receive safe, healthful, and comfortable accommodations, interference with eating, intimidation, or other actions of a punitive nature. LPA informed the Licensee that fire/disaster drills must be practiced at least once every 6 months and documented.

Licensee provided proof of control of property to the Department prior to today’s inspection and a copy of the lease agreement is on file. LPA observed the Property Owner/Landlord Notification form (LIC 9151) that the Licensee confirms was provided to the property owner/landlord. Licensee does not have liability insurance at this time and will issue Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282) to all enrolling families until she obtains liability insurance in the future. The Licensee has not obtained a signed Property Owner/Landlord Consent form (LIC9149). Without this consent, the applicant understands that, once licensed, they can operate with a maximum capacity of 12 children.

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SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: MUMZHU, TATYANA	FACILITY NUMBER: 434415925
	VISIT DATE: 01/22/2025

NARRATIVE

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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.

Licensee, Tatyana Mumzhu, 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.

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. Pre-licensing Entrance Checklist – Family Child Care Homes (LIC 9280) was provided to the Applicant.

LPA discussed the safe sleep regulations with Applicant, Tatyana Mumzhu, 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, 1/14/2025, 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: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: MUMZHU, TATYANA	FACILITY NUMBER: 434415925
	VISIT DATE: 01/22/2025

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Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care 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 at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with the Licensee, Tatyana Mumzhu. LPA advised the Licensee that the approval for active status of the license will be approved pending completion of item below and pending Licensing Program Manager’s review.

Pending items to be completed:

Copy of current 1st Aid/CPR certificate

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

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