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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343617941
Report Date: 04/23/2024
Date Signed: 04/23/2024 12:57:24 PM


Document Has Been Signed on 04/23/2024 12:57 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SAMUSENKO, LYUBOVFACILITY NUMBER:
343617941
ADMINISTRATOR:SAMUSENKO, LYUBOVFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 429-5752
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:14CENSUS: 11DATE:
04/23/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Lyubov SamusenkoTIME COMPLETED:
01:15 PM
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On April 23, 2024, Licensing Program Analyst (LPA) Stephanie Piring met with Licensee, Lyubov Samusenko, for an unannounced annual / one year inspection. During the inspection there was a census of 11 children in care being supervised by the licensee and assistant. All individuals subject to criminal background review have obtained a criminal record clearance. Facilities hours of operation are Monday through Friday 07:00 AM to 06:00 PM.

A health and safety inspection was conducted in the areas accessible to children. The off-limits areas include: Garage, Laundry, Daughter room, side and far back gated yard. Licensee understands that children may never enter off-limits areas. LPA observed a working telephone, functioning smoke and carbon monoxide detector, and a fully charged 2A10BC fire extinguisher within the home. LPA observed home was safe, orderly, and free of hazards. LPA observed a variety of age-appropriate toys within the home. LPA observed fireplace within the home is properly barricaded to meet regulations. Licensee stated there are no firearms or bodies of water on the premises. Licensee understands that if there are any poisons in the home, all poisons must be locked with a key lock or combination lock.

LPA observed all required postings, a children's roster and fire drill log, the last fire drill was conducted 03/21/2024. LPA reviewed records of children’s files and staff files, all which contained the required documentation. Licensee has current EMSA approved pediatric CPR/First Aid training, which expires 07/2025. Adult Assistant also has current EMSA approve pediatric CPR/First Aid Training. Mandated Reporter Training is not offered in applicant’s primary language, therefore she is exempt from the training.

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.

Page 1 of 2 Continued on LIC809-C

SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 263-5714
LICENSING EVALUATOR NAME: Stephanie PiringTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SAMUSENKO, LYUBOV
FACILITY NUMBER: 343617941
VISIT DATE: 04/23/2024
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Although Licensee is not currently caring for any infants, LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee [or facility representative] 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/.

Licensee was informed of the MyChildCarePlan.org website; 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.

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.

No Title 22 deficiencies are being cited based on today’s inspection

During the exit interview, the licensee, Lyubov Samusenko, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Exit interview conducted and report was reviewed with the licensee, Lyubov Samusenko. A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 263-5714
LICENSING EVALUATOR NAME: Stephanie PiringTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC809 (FAS) - (06/04)
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