434416805-8-28-2024-07-CC-MMOO-D8KVFW-20240828162438

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416805
Report Date: 08/28/2024
Date Signed: 08/28/2024 04:24:46 PM

Document Has Been Signed on 08/28/2024 04:24 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	TSYMBALIUK, ALONA		FACILITY NUMBER:	434416805
ADMINISTRATOR/ DIRECTOR:	ALONA, TSYMBALIUK		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(669) 261-9772
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 17	CENSUS: 8	DATE:	08/28/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:31 PM
MET WITH:	Alona Tsymbaliuk		TIME VISIT/ INSPECTION COMPLETED:	04:40 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	On August 28, 2024 at 1:31 PM, Licensing Program Analyst (LPA), Marilou Monico, conducted an unannounced Annual Random inspection. LPA met with Licensee, Alona Tsymbaliuk, and explained to her the nature of today's inspection. Licensee was alone in the home together with eight (8) preschool age children when LPA arrived. All required posting materials were posted. Licensee's helper (S1) arrived at 1:40 PM. The daycare is open Monday thru Friday from 8:00 AM to 6:00 PM. There are no active waivers or exceptions for this facility. The daycare is a two storey home with 5 bedrooms and 2 1/2 baths. Per Licensee, the adults that reside in the home are herself and her husband. LPA obtained a copy of current children's roster during the inspection. Fire/disaster drill was conducted on August 2, 2024. LPA observed a fully charged 4A60BC fire extinguisher, functioning smoke and carbon monoxide detectors, covered fireplace, gated stairs and kitchen. Licensee states that there are no weapons or firearms in the home. LPA discussed and provided licensee with the ratio and capacity chart. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care Homes, Section 102417. 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 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 Licensee, 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, 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. Continuation on next pages:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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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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: 08/28/2024

NARRATIVE

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Off limit areas inside the home are: entire upstairs including 4 bedrooms, 2 bathrooms, and upstairs terrace, downstairs hallway closet, kitchen, and garage. LPA observed that the home is clean and orderly. Cleaning products, sharp objects, and other items that are dangerous to children were stored inaccessible. LPA 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: (669) 262-9772. Off limit areas outside the home: left side yard.

LPA reviewed eight (8) children's files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Affidavit Regarding Liability Insurance (LIC 9182), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization Records.

LPA reviewed two helper's files for the following records: Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), immunizations, TB test, and required training. Licensee has immunization in measles, pertussis and flu. Licensee has current Mandated Reporter Training certificate that was completed on February 23, 2023. Licensee has current Pediatric CPR/First Aid certifications with an expiration date of May 5, 2025. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years.

LPA provided and discussed the safe sleep regulations with Licensee 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 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 they register 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: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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: 08/28/2024

NARRATIVE

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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, Alona Tsymbaliuk, 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.

As a result of today's inspection, Type A deficiency was cited on the following page.

Assembly Bill (AB) 633 was provided and discussed with Licensee. LPA informed Licensee to provide a copy of this licensing report dated 08/28/24 that documents a Type A citation to parents/guardians of all children currently enrolled no later than the next business day or the next day the children are in care, and to parents/guardians of any newly enrolled children for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC9224) must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with Alona Tsymbaliuk, Licensee.

During the exit interview, the Licensee, Alona Tsymbaliuk, 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 POSTED FOR 30 DAYS.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/28/2024 04:24 PM - It Cannot Be Edited

Created By: Marilou Monico On 08/28/2024 at 03:32 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: TSYMBALIUK, ALONA	FACILITY NUMBER: 434416805
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102416.5(e)

Staffing Ratio and Capacity

(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee was by herself supervising eight (8) preschool age children which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2024
	Plan of Correction
1 2 3 4	Licensee's helper (S1) arrived during the inspection. By POC due date: 08/29/24, licensee states she will submit a written plan to ensure that the home is within the required ratio and capacity at all times. Licensee submitted written Plan of Correction during the inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Joel Segura

LICENSING EVALUATOR NAME:

Marilou Monico

LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC809 (FAS) - (06/04)

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