434416805-2-23-2023-07-CC-MMOO-CPBQKS-20230223111449

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416805
Report Date: 02/23/2023
Date Signed: 02/23/2023 11:14:57 AM

Document Has Been Signed on 02/23/2023 11:14 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, ALONA		FACILITY NUMBER:	434416805
ADMINISTRATOR:	ALONA, TSYMBALIUK		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(669) 261-9772
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	02/23/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Alona Tsymbaliuk		TIME COMPLETED:	11:25 AM

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	On February 23, 2023 at 9:04 AM, Licensing Program Analyst (LPA) Marilou Monico conducted an announced Prelicensing Inspection in response to a request for a change of location. LPA met with Alona Tsymbaliuk, Applicant, and explained the nature of today's visit. Also present in the home was Applicant's husband. LPA notes that the Applicant is licensed at 4624 Winding Way, San Jose, CA 95129 (Facility number: 434416805). Per Applicant, the adults that reside in the home are herself and her husband. Applicant states that her two children ages 15 and 10 years old also live in the home. The home is two-storey with 5 bedrooms and 2 1/2 bath. Days and hours of operation will be Monday - Friday from 8:00 AM to 6:00 PM. Applicant has completed the Preventative Health and Safety Child Care Training and a copy of the certification is on file. Applicant's CPR and First Aid certifications are current and expire on May 8, 2023. Applicant completed the Mandated Reporter Training on February 1, 2022. Applicant's immunizations in measles, pertussis, and flu are on file. Applicant and her husband own the home and copy of grant deed was submitted to Licensing. Applicant states that she is planning to obtain daycare insurance once licensed. LPA toured the indoor and outdoor areas of the home during today's inspection. LPA observed barricaded stairs, glass covered fireplace, gated kitchen, fully charged 4A60BC fire extinguisher, working smoke and carbon monoxide detectors, and fenced backyard. Off limit areas inside the home are: entire upstairs including 4 bedrooms, 2 bathrooms, and upstairs terrace, downstairs hallway closet, kitchen, and garage. Off limit areas outdoor: left side yard. The home is clean and orderly, with heating/air conditioning, and ventilation for safety and comfort. There is sufficient toys, supplies, and equipment for the day care children both indoor/outdoor. There were no bodies of water observed. Applicant states that there are no weapons in the home. Continuation on next pages:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

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: 434416805
	VISIT DATE: 02/23/2023

NARRATIVE

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Forms of discipline used by Applicant: talking to children and redirection. Cleaning products, toxic agents, medications, and sharp objects were inaccessible to children. LPA reminded Applicant that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes.

Applicant understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed. LPA informed Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

Applicant, Alona Tsymbaliuk, 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, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the requirements of Assembly Bill(AB) 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

LPA provided and discussed the safe sleep regulations with Applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/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 she registers all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Continuation on next page:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: TSYMBALIUK, ALONA	FACILITY NUMBER: 434416805
	VISIT DATE: 02/23/2023

NARRATIVE

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LPA provided and reviewed 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.

Incidental Medical Services (IMS) policy was discussed. Applicant states that she is not planning to provide IMS at this time. 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: http://www.ada.gov/childqanda.htm.

PIN 22-02-CCP - Best Practices Related to the Provision of Incidental Medical Services in Child Care Center and Family Care Homes was provided to Applicant.

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 February 13, 2023.

Exit interview conducted and report was reviewed with the Applicant, Alona Tsymbaliuk and advised her that a license for a Large Family Child Care Home will be submitted to Licensing Management for the final stage of approval.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC809 (FAS) - (06/04)

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