435700366-6-23-2023-52-CC-MESA-CT3R4Z-20230623124222

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435700366
Report Date: 06/23/2023
Date Signed: 06/23/2023 12:42:29 PM

Document Has Been Signed on 06/23/2023 12:42 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	DZHYLIALOVA, NIIARA		FACILITY NUMBER:	435700366
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 6	DATE:	06/23/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Niiara Dzhylialova		TIME COMPLETED:	01:00 PM

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On 06/23/2023 at 9:30 am, Licensing Program Analysts (LPAs) Manel Estoesta and Jaleesa Jackson conducted an unannounced Case Management Visit - Incident. LPAs met with the Licensee Niiara Dzhylialova and explained the nature of the visit. Licensee speaks Russian and LPAs requested to a Language Link Translator. Present on this visit were 1 adult living in the home - Kyrylo, 4 infants and 2 preschool children in care and Licensee's Assistant Leniie. The home operates from Monday to Friday 7am to 6pm.

On 06/02/2023, the licensee reported an Unusual Incident to the Regional Office (RO). The summary of the unusual incident phone call was as follows;
On 06/02/2023 at 10:25 am, Child was coming from potty time and licensee offered child a toy to play with. Child was walking from potty and fell and injured their leg. Assistant applied ice and licensee contacted mother. Child was picked and taken to ER for care. Mom called to tell Licensee that child had a broken right leg.

The licensee had a camera footage on 06/02/2023, no time stamp of the incident and LPAs viewed the camera footage with the Licensee. The footage showed 5 children in the day care room with the Licensee, C1 was walking towards the Licensee, Licensee was assisting a child on a potty chair, C1 was holding something that look like a small blanket on her right hand and C1 picked a toy with her left hand. C1 looked like she tripped due to out of balance and fell on a foam play mats right behind a child on the potty chair. The camera angle did not show the time C1 fell due to another child is blocking C1. Licensee reach to C1 and checked her legs. The camera footage ended on that with 20 seconds of recording.

As per the Licensee, Licensee applied ice on C1 leg as a first aid. Licensee sent a text to C1's parent at 11:34 am to report the incident, C1 parents picked up C1 an hour after. C1 was brought to the hospital that same day and C1 returned on 06/05/2023 with a cast on her leg.

C1 was not present during todays visit. See 809 C.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Manel Estoesta
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: DZHYLIALOVA, NIIARA	FACILITY NUMBER: 435700366
	VISIT DATE: 06/23/2023

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Continuation...

LPA Estoesta obtained a copy of the camera footage sent to LPA's mobile phone.

Based on the LPA's observation, C1's injury was due to C1 falling on the foam play mats while walking towards the Licensee. There was nothing to prevent the fall from occurring and not due to lack of supervision.

Licensee's assistant Leniie Useinova is associated to MISHYNA, HULIZAR - 435700321 but not to the licensee's day care. LPAs advised the licensee to complete an LIC 9182 to transfer Leniie's fingerprints to Licensee's day care. See Technical Violation.

At 9:50 am, LPAs observed 4 infants and 2 preschool children in care. The Licensee was in violation of 102416.5(b)(2) Six children, no more than three of whom may be infants.

LPAs advised the licensee that this report includes a Type B citation with above violation.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee, Niiara Dzhylialova.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Manel Estoesta
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/23/2023 12:42 PM - It Cannot Be Edited

Created By: Manel Estoesta On 06/23/2023 at 11:27 AM

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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: DZHYLIALOVA, NIIARA	FACILITY NUMBER: 435700366
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/26/2023 Section Cited CCR 102416.5(b)(2)	1 2 3 4 5 6 7	Staffing Ratio and Capacity 102416.5 For a Small Family Child Care Home, the maximum number of children for whom care ....... (2) Six children, no more than three of whom may be infants; or....	1 2 3 4 5 6 7	The Licensee will disenroll one infant or arrange children's schedule that the staff -ratio is six children, no more than three of whom may be infants or 4 infants only. Licensee will submit an LIC 9040 and the new day care children schedule.....
	8 9 10 11 12 13 14	At 9:50 am, LPAs observed 4 infants and 2 preschool children in care. The Licensee is out of staff children ratio which poses a potential health and safety to children in care.	8 9 10 11 12 13 14	LPA's advised the Licensee to apply for a large FCCH license. LPAs provided copies of Staff Ratio regulation and LIC 311 D. POC documentation submission due date is 06/26/2023.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

Jason Jang

LICENSING EVALUATOR NAME:

Manel Estoesta

LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC809 (FAS) - (06/04)

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