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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416371
Report Date: 01/03/2024
Date Signed: 01/03/2024 05:19:49 PM

Document Has Been Signed on 01/03/2024 05:19 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:MANKOVSKAJA, LUDMILAFACILITY NUMBER:
434416371
ADMINISTRATOR:MANKOVSKAJA, LUDMILAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 656-7685
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
01/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ludmila MankovskajaTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sheena Chin conducted a case management at the facility and met with the licensee, Ludmila Mankovskaja. Present were the licensee, the helper and 7 children in care.

The licensee hired a helper, S1, on 1/2/24 but the helper did not have the required documents. The helper finished LIC 508, the criminal record statement and LIC 9163, request for live scan service, however, the criminal record clearance has not yet granted to the helper. The helper did not have the mandated reporter training certificate either. LPA advised the licensee that the helper is not allowed to work in the facility until her background is cleared.

Deficiencies were cited and city penalty was assessed.

Exit interview was conducted, where this report, the citation, plan of correction, and appeal rights were reviewed and discussed with Licensee, Ludmila Mankovskaja.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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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Document Has Been Signed on 02/21/2024 01:42 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/18/2024 02:56 PM


Created By: Sheena Chin On 01/03/2024 at 12:18 PM
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MANKOVSKAJA, LUDMILA
FACILITY NUMBER: 434416371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2024
Section Cited
HSC
1596.871(c)(1)(A)

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1596.871 (c)(1)(A) A person...shall obtain either a criminal record clearance or an examption from disqualification...from the State Department of Social Services prior to empolyment...

This requirement is not met as evidenced by :
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The licensee will not have the helper work in the facility until the criminal background check is granted.
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Based on record reviews, the licensee did not comply with the section cited above. The facility hired a helper, who did not have criminal record clearance, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
01/29/2024
Section Cited
HSC1596

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No deficiency cited for this section
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Sheena Chin
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024


LIC809 (FAS) - (06/04)
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