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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435700366
Report Date: 07/13/2022
Date Signed: 07/13/2022 11:12:59 AM

Document Has Been Signed on 07/13/2022 11:12 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:DZHYLIALOVA, NIIARAFACILITY NUMBER:
435700366
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
07/13/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Niiara Dzhylialova, Oleksandr MishynTIME COMPLETED:
11:15 AM
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On 7/13/2022 at approximately 9:11am Licensing Program Analyst(LPA) Sabina Dodoo and Licensing Program Manager(LPM) Chandra Charles met with applicant Niiara Dzhylialova and her interpreter Oleksandr Mishyn for an Announced Office Meeting at the Oakland South East Regional Office. The purpose of the meeting is to help applicant complete LIC 279 correctly and to discuss the missing documents needed in order for the application to be complete.

LPM Charles advised the applicant that she currently does not have a criminal background clearance associated to the pending facility license. Applicant was reminded that all adults living in the house must also obtain a criminal background clearance before the applicant can be licensed. Applicant completed a new LIC 279 form and submitted it to LPA Dodoo. The applicant was reminded a translator might be needed during the pre-licensing visit in order for LPA to complete the inspection.

During the office visit LPA obtained a copy of the Mandated Reporter training, and an LIC 9163 Live Scan form. LPM reminded applicant that CPR and Mandated Reporter is valid for only two years and will have to be renewed in the next two years. LPM and LPA discussed the regulations for small Family Day Care Homes and larger Family Day Care Homes. LPA requested a copy of Rental/ Lease agreement with shows that she is one of the tenant that controls the property. All required documents must be submitted no later than 7/20/2022.

Exit interview was conducted with applicant Niiara Dzhylialova and interpreter Oleksandr Mishyn. A copy of this report was given to applicant. This report shall remain on file for 3 years.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Sabina Dodoo
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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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