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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 485407563
Report Date: 11/17/2023
Date Signed: 11/17/2023 03:36:59 PM

Document Has Been Signed on 11/17/2023 03:36 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SHAVRATOV FAMILY CHILD CARE HOMEFACILITY NUMBER:
485407563
ADMINISTRATOR:SHAVRATOV, ZINAIDA & EFIMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 305-1857
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 9DATE:
11/17/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Efim Shavratov and Zinaida ShavratovTIME COMPLETED:
03:50 PM
NARRATIVE
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A required inspection was made to the facility by Licensing Program Analyst (LPA), Melchisedeck Augustin. A review of staff records on 11/17/2023 indicates that all facility staff or other individuals who require caregiver background checks received a criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, 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.


During today’s inspection the home and grounds were toured. The Licensee and Co-Licensee (LS & LS1) and one volunteer (V1) were supervising 9 children and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 7:00AM to 5:00PM, Mon–Fri. The floor plan submitted by the licensees were reviewed and verified. The off-limits areas of the home are the entire second floor, one bedroom on the first floor and garage and were made inaccessible by means of a children’s safety gates. The staircase was barricaded with a child safety gate. The home was at a comfortable indoor temperature. There were safe toys available for children. There is a working telephone in the home. Licensees' pediatric CPR/First Aid certification expire 05/21/2025. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. There is a functional smoke and carbon monoxide detectors; and a fully charged fire extinguisher rated at least 2A10BC. Licensees confirmed they did not store any firearm(s) or other dangerous weapon(s) on the premise. LPA observed a container of accessible insect poison stored in a shed in the backyard, and the shed did contain a key or combination lock. LS and LS1 did not furnish current AB 1207 Mandated Reporter Training certificates. Furthermore, Licensees did not furnish required immunization record for V1. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 11/17/2023 03:36 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 11/17/2023 at 02:24 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SHAVRATOV FAMILY CHILD CARE HOME
FACILITY NUMBER: 485407563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations of an accessible container of insect poison(s) stored in a shed that was not key or combination locked. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2023
Plan of Correction
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The Licensees stated they would make the container of insect poison inaccessible by either move the poison from the shed or intall a key or combination lock on the exterior doors of the shed in the back yard. The Licensee agreed to provide evidence of compliance to the Department by 11/18/23.
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the facility's disaster drill log which revealed the facility did not conduct at least one emergency disaster drill within the past six months. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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The Licensee stated he would conduct an emergency disaster drill, update the drill log and complete the LIC 9098, and submit the updated log along with completed LIC 9098 to the Department by 12/04/23 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/17/2023 03:36 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 11/17/2023 at 02:24 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SHAVRATOV FAMILY CHILD CARE HOME
FACILITY NUMBER: 485407563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Licensees not furnishing evidence to prove they did/had conducted 15 minute checks while C1-C4 took a nap. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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The Co-Licensee agreed to initiatee 15 minute checks,document at least four days worth of 15 minute checks, and submit the Infant Sleep Log with completed LIC 9098 to the Department by 12/04/23 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Licensees' statements confirming they did not have a current Mandated Reporter Training certificates. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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Co-Licensee stated LS and LS1 would complete the online Mandated Reporter Training module at mandatedreporterca.com, and Licensees intends to submit their current certificates to the Department by 12/04/23 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/17/2023 03:36 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 11/17/2023 at 02:24 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SHAVRATOV FAMILY CHILD CARE HOME
FACILITY NUMBER: 485407563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff (LS, LS1 & V1) records reviewed at 1:13pm which revealed V1's record did not contain required staff immunization record. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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Licensees stated they would ensure V1 obtained proof of immunity against Measles, Pertussis and Influenza, and would submit evidence of V1's required immunization to the Department by 12/04/23 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


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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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SHAVRATOV FAMILY CHILD CARE HOME
FACILITY NUMBER: 485407563
VISIT DATE: 11/17/2023
NARRATIVE
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LPA reviewed five children’s (C1-C5) records at 1:26pm which revealed the records contained Consent for Emergency Medical Treatment (LIC 627), Identification and Emergency Information form (LIC 700), Parent Notification of Additional Children in Care (LIC 9150), and Notification of Parent’s Rights (LIC 995A), Immunization Records (IR); and IR were transcribed onto the blue CDPH 286. According to the facility’s disaster drill log, the facility did not conduct an emergency drill within the past six months and the last drill was documented on 01/01/23. The facility roster of the children in care was reviewed and appeared to be complete. There were four children under two years old present, there were five play yards available for the children to use, C1-C4’s records contained completed LIC 9227; and the Licensees did not provide evidence to prove they were/had conducted 15-minute checks while C1-C4 took a nap. LPA did not observe any bodies of water.

LPA discussed the safe sleep regulations with licensees 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 licensees 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.

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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

On this date, 11/17/2023, 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. (Continue to LIC 809-C)

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
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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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SHAVRATOV FAMILY CHILD CARE HOME
FACILITY NUMBER: 485407563
VISIT DATE: 11/17/2023
NARRATIVE
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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.


Exit interview conducted and report was reviewed with the Licensees, Zinaid Shavratov and Efim Shavratov. 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. The following violations of the California Code of Regulations, Title 22; Division 12, were observed during today’s visit. See LIC 809-D. Appeal Rights
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
LIC809 (FAS) - (06/04)
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