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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416238
Report Date: 01/10/2025
Date Signed: 01/14/2025 02:56:18 PM

Document Has Been Signed on 01/14/2025 02:56 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:MURZIANKOVA, KATSIARYNA & CAMACHO, JAIMEFACILITY NUMBER:
434416238
ADMINISTRATOR/
DIRECTOR:		KATSIARYNA & JAIMEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 542-9331
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 9DATE:
01/10/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:39 AM
MET WITH:Katsiaryna Murziankova & Jaime CamachoTIME VISIT/
INSPECTION COMPLETED:
02:50 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 Analysts (LPAs) Mandeep Kaur and Angela Luz conducted an Required-3 year inspection. LPAs met with Licensees, Katsiaryna Murziankova & Jaime Camacho , and explained the reason for the inspection. Also, present in the home were 9 children including 4 infants and two Assistants(S1&S2). The licensees and their son are the only adults residing in the home. Licensees have one minor child, also residing in the home.

The hours of operation are Monday through Friday 07:30AM to 5:30PM. LPAs obtained a copy of current children's roster during the inspection. Fire/disaster drill was conducted on July 10, 2024. Licensees were reminded that fire/disaster drill needs to be conducted and documented every six months. LPAs observed a fully charged 2A10BC fire extinguisher with the purchased receipt of 06/2024. functioning smoke and carbon monoxide detectors. Licensee states that there are no weapons or firearms in the home.

LPAs toured the indoor and outdoor areas of the home with Licensee, Katsiaryna Murziankpova. LPAs observed that the home is clean and orderly. Cleaning products, ,sharp objects, and other items that are dangerous to children were stored inaccessible. LPAs observed sufficient age-appropriate materials, toys, and play equipment in the home. The children's bathroom is clean, sanitary, and operable. The home has a working telephone. The off limit areas are: Bedroom 2.

**Continue on 809-C**
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MURZIANKOVA, KATSIARYNA & CAMACHO, JAIME
FACILITY NUMBER: 434416238
VISIT DATE: 01/10/2025
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
LPAs reviewed six (6) children's files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC 282), and Immunization Records.

LPAs reviewed two(2) assistants files for the following records: Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), TB test, and required training. Licensees and her adult helper have immunizations in measles, pertussis and flu. Licensees have a valid CPR/1st Aid, which expires on 09/2025. Licensees completed Mandated Reporter training certificates expire on 10/30/2026. LPAs reminded Licensees that the Mandated Reporter training and CPR/1st Aid requires renewal every two years. Licensees immunization records for TB, measles, pertussis, and influenza are also on file.


LPAs discussed the safe sleep regulations with Licensee and discussed 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. LPAs also reminded 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 she registers all infant devices with the CPSC to be notified of any recalls on their purchased
equipment.

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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee, Katsiaryna Murziankova 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.
**Continue on next page**
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC809 (FAS) - (06/04)
Page: 2 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MURZIANKOVA, KATSIARYNA & CAMACHO, JAIME
FACILITY NUMBER: 434416238
VISIT DATE: 01/10/2025
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
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.

Licensee, Katsiaryna Murziankova, was informed of the MyChildCarePlan.org website; a consumer education
website that helps families obtain child care by connecting them to child care providers and Resource and
Referral Agencies (R&R's) throughout California.

No Deficiency is issued during today's inspection.

Exit interview conducted and report was reviewed with Licensee, Katsiaryna Murziankova.

During the exit interview, the Licensee, Katsiaryna Murziankova, confirmed that there are no Registered Sex
Offenders living in the facility and LPA completed the RSO profile in FAS.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN FOR 30 DAYS.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3