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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417211
Report Date: 10/28/2024
Date Signed: 10/28/2024 03:08:15 PM

Document Has Been Signed on 10/28/2024 03:08 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:KELEKHSAEVA, TSISANAFACILITY NUMBER:
434417211
ADMINISTRATOR/
DIRECTOR:		TSISANA KELEKHSAEVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 775-1319
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
10/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Tsisana KelekhsaevaTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA)Anna Morales conducted an Unannounced Pre-Licensing Inspection and met with Applicant Tsisana Keleskhsaeva. Applicant stated that the she is the only adult who is residing at the facility. Applicant has been fingerprint cleared and associated. Hours of operation will be Monday- Friday, 8am-6pm, ages 18 months to 6 six years of age. Fire clearance was granted on 10/18/24.

Tsisana Keleskhsaeva, 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.

The Applicant completed the Preventative Health and Safety Child Care Training on 10/12/24. Pediatric CPR and First Aid training expires on 8/31/26.


A copy of current TB test, flu, MMR, and Tdap vaccinations for the Applicant are on file. Mandated Reporter Training for Child Care Workers is being waived The Applicant does not have liability insurance at this time and will issue Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282) until she obtains insurance coverage.
LPA toured the indoor and of the facility during today's inspection. The facility is a single story home with three bedrooms and two bathrooms, living room and kitchen. LPA observed FE3A40GR fire extinguisher, smoke detector and carbon monoxide detectors. All toxic and sharp objects were stored in a locked cabinet. Applicant stated that the children will have access to the living room, front bathroom, bedroom Number One. Applicant stated that the children will not have access to the Master Bedroom/bathroom, Bedroom 2 and kitchen. The outside areas, Applicant stated that the children will have access to backyard and front yard. In the backyard, the children will not have access to the storage shed. LPA observed a secured fence and age appropriate play structures and toys. The home is clean and orderly, with heating and ventilation for safety & comfort.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KELEKHSAEVA, TSISANA
FACILITY NUMBER: 434417211
VISIT DATE: 10/28/2024
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LPA observed sleeping mats, tables/chairs(children) and age appropriate toys.

Applicant provided proof of control of property. Because the Applicant rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS: 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) or (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.

LPA reviewed with Applicant 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. Entrance Checklist was provided to the applicant.

LPA 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-andresources/safe-sleep, as an additional resource. LPA also informed Tsisana Keleskhsaeva 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.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KELEKHSAEVA, TSISANA
FACILITY NUMBER: 434417211
VISIT DATE: 10/28/2024
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Forms of discipline used by Applicant: talking to children/redirection. Applicant that smoking, baby walkers, Jumpers, bouncers 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.

On this date, 9/9/24, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant Tsisana Kelekhsaeva was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Exit interview conducted and report was reviewed with Applicant Tsisana Kelekhsaeva.

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 platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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