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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416335
Report Date: 10/06/2021
Date Signed: 10/06/2021 11:21:32 AM

Document Has Been Signed on 10/06/2021 11:21 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:TSYMBALIUK, ALONAFACILITY NUMBER:
434416335
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
10/06/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alona TsymbaliukTIME COMPLETED:
11:16 AM
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On 10/6/2021 at 9:30am: Licensing Program Analyst (LPA) Pete Hernandez conducted an announced Pre-licensing for a Small Family Child Care Home. Applicant recently moved to a new home and wishes to relocate her Family Child Care Home. LPA met with Applicant, Alona Tsymbaliuk and explained the purpose of today's inspection and to address the licensees request for a Pre licensing for a Large Family Home. Present in the home was her husband . Applicant lives in the home with her husband: Sergii Tsymbaliuk. Appplicant also lives with her two minor sons. Applicant rents the home. Applicant will provide an affidavit to parents that she does not carry insurance. The hours of operation are Monday through Friday 8:00AM to 6:00PM.
LPA toured the indoor and outdoor areas of the home during today's inspection:
In Use Areas: Living Room, Activity Room, downstairs bathroom, and downstairs bedroom. Off Limit Areas: Master bedroom and master bathroom, kitchen, entire upstairs and Garage. Outdoors: Back yard is fenced and available for the children to use. (Both side yards are barricaded and off limits to the children.)
Fire drills are to be conducted are every 6 months. Applicant will maintain a current children's' roster. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is orderly, and safe for the day care children.
LPA observed a fully charged 3A40BC fire extinguisher in the kitchen. There are working smoke & carbon monoxide detectors in the home. LPA did not observe any bodies of water on the immediate property. The Applicant understands that all pools, spas, hot tubs, fish ponds, or similar bodies of water shall be covered or fenced as specified in title 22 regulations to be inaccessible to children. Applicant states that there are no weapons or firearms in the1 home. All detergents, cleaning compounds, other similar items and poisons are out of reach, and are inaccessible to children.
REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 10/6//2021:
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: TSYMBALIUK, ALONA
FACILITY NUMBER: 434416335
VISIT DATE: 10/06/2021
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Incidental Medical Services (IMS) policy was discussed. When any IMS is provided, an updated Plan of Operation that includes 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

A review of staff records today 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 also reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12- month period

Supervision of children was discussed with the Applicant. Applicant understands that she must be present in the home at least 80 percent of the hours the day care is in operation and ensure that the children are supervised at all times. The Applicant understands her capacity options. The Applicant states that she does transport children and understands that children cannot be left in parked vehicles unattended at any time. Applicant understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick child, requirements for reporting suspected child abuse, unusual incidents/injuries, heat-related illnesses, and requirements for assistant/substitute were also discussed.
LPA informed Applicant that Licensing forms and Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov

LPA reviewed the pre licensing packet with the Applicant.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #3 - REPORT DATED 10/6//2021:
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: TSYMBALIUK, ALONA
FACILITY NUMBER: 434416335
VISIT DATE: 10/06/2021
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Licensee does have current Mandated Reporter Certificate and will expire on 11/20/21. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed at www.mandatedreporterca.com.
Licensee has a current CPR and First Aid card that expires 05/8/23.
Website for resource information: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list, childcareadvocatesprogram@dss.ca.gov

Applicant has relocated to a new home and understands that the license is to be reviewed by Management prior to licensing approval.

Upon the issuance of Type A citations, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, and Plan of Corrections were reviewed and developed with the Applicant. A copy of this report and appeals rights were discussed and left with the Applicant, Alona Tsymbaliuk , whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC809 (FAS) - (06/04)
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