Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343617941
Report Date: 03/01/2016
Date Signed: 03/01/2016 02:40:19 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:SAMUSENKO, LYUBOVFACILITY NUMBER:
343617941
ADMINISTRATOR:SAMUSENKO, LYUBOVFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 727-3271
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:14CENSUS: 9DATE:
03/01/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Lyubov SamusenkoTIME COMPLETED:
03:00 PM
NARRATIVE
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#1 Licensing Program Analysts (LPAs) Steven Lunn and Tanya Washington met with Licensee and conducted an annual random visit at the home. LPA Washington interpreted during the visit. LPAs and Licensee toured the home. LPA observed the care and supervision of nine children in care. The main area for care is in the living room and daycare room near back of home. Off-limit areas of the home include the garage, both daughters rooms and laundry room. Licensee acknowledged that children may never enter these off-limit areas. Bathroom was inspected. The backyard is completely fenced. Licensee states she does not offers liability insurance. All adult residents have criminal record clearances. CPR/First Aid certificate for Licensee expires 5/2017. Facility roster, children’s files and facility documents were reviewed. Fire drills are documented, fire extinguisher, smoke detector and carbon monoxide detector meet regulation requirements. Fireplace was found screened and inaccessible to children. Medications are inaccessible to children. LPAs observed some shampoo's and personal hygiene items under the bathroom sink. There is a working telephone, and toys appear to be safe. Licensee stated there are no weapons in the home and LPA observed no bodies of water. This facility is not providing Incidental Medical Services-IMS at this time. LPA discussed IMS services and the requirement to create a plan of operation. Specifics on the plan can be found in the family child care home evaluator manual (FCCH EM) Policy 102417.

LPA discussed the following with Licensee: SB 277- Public health: Vaccinations, AB 1387 – Care facilities- civil penalties, deficiencies and appeal procedures. The Licensing Agency Website is
(www.ccld.ca.gov), so the licensee may obtain updated licensing information, regulations, and forms.

The following deficiencies were observed:
Upon receipt, the licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 provided to Licensee.

Exit interview was conducted. Appeal rights provided. Notice of site visit posted.
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Steven LunnTELEPHONE: 916-216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2016
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: SAMUSENKO, LYUBOV
FACILITY NUMBER: 343617941
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2016
Section Cited
102417(g)(4)
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Operation of a Family Child Care Home. Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger to children shall be stored where they are inaccessible to children. LPAs observed flea/tick shampoo and personal hygiene items accessible to children.
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Licensee stated she would move the items to a higher cabinet immediately.

Type A
03/02/2016
Section Cited
102417(g)
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Operation of a Family Child Care Home. The home shall be free from defects or conditions which might endanger a child. LPAs observed on the side yard accessible to children an exercise equipment, glass bottles, dishwasher, vehicle tires(tire rims), car ramps and an unlocked storage shed with items dangerous to children.
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Licensee stated she will have her husband clean up the side yard and remove the items accessible to children. Licensee to submit picture proof of clean up of side yard to Licensing by 3/2/2016.

Steven.Lunn@dss.ca.gov
Type A
03/02/2016
Section Cited
102423(a)(2)
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Personal Rights. Each child shall be accorded safe, healthful and comfortable accommodations, furnishing and equipment. LPAs observed an infant sleeping in a stroller with a blanket over the stroller in the front bedroom.
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Licensee stated the parents requested the child to sleep in the stroller. Licensee stated she will try a cot for the child or a playpen. She said she will inform parents the regulation for Personal Rights.
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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: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Steven LunnTELEPHONE: 916-216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2016
LIC809 (FAS) - (06/04)
Page: 2 of 2