Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343617941
Report Date: 02/01/2019
Date Signed: 02/01/2019 12:53:17 PM

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) 429-5752
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:14CENSUS: 7DATE:
02/01/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Lyubov SausenkoTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jeremey McClain met with licensee Lyubov Samusenko for an annual/random inspection. Licensee’s husband was present during today’s inspection. LPA observed a census of seven children, which included two infants and five preschool age children. Licensee stated there are no new residents in the home, and all adult residents have criminal record clearances.

LPA toured areas of the home accessible to the children. The off-limit areas are: the garage, the laundry room, licensee’s daughter’s room and parts of the backyard that are gated off. Licensee acknowledged that children may never enter these off-limit areas.

LPA observed current CPR/First Aid certificate which expires: 5/2019. LPA observed the following posted: a license, a Parents' Rights Poster and an Emergency Disaster Plan. LPA reviewed children’s records for completeness, as well as the client roster. Licensee provided proof of immunizations for MMR, Pertussis, and influenza.

LPA observed that hazardous items (detergents, cleaning compounds, medication, sharp utensils, and other items that could pose a danger to children in care) are properly stored out of children's reach. LPA observed a fire place that was properly screened. There is a working telephone in the home. Licensee stated there are no weapons in the home. Licensee’s fire extinguisher, carbon monoxide and smoke detector meet regulation. LPA observed fire drills documented on a calendar, indicating that the licensee is conducting disaster drills at least once every 6 months. Toys appear to be safe and in working order. The backyard is fenced. LPA did not observe any bodies of water on the premises.
REPORT CONTINUED ON THE FOLLOWING PAGE...
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Jeremey McClainTELEPHONE: (916) 216-7801
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2019
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
VISIT DATE: 02/01/2019
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LPA provided the Licensing Agency website (www.ccld.ca.gov), so the licensee may obtain updated licensing information, regulations, and forms.

Incidental Medical Services (IMS) policy was discussed and the licensee is not currently providing IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

LPA discussed recent changes in licensing requirements, including AB1207 Mandated Reporter training. Licensee and assistants have completed the required training. LPA reminded licensee that the training must be completed once every two years.



LPA informed licensee about Safe Sleep Regulations Concepts and provided licensee with the associated Provider Information Notice (PIN).

No deficiencies were issued during today’s inspection.



This report was reviewed with licensee, and an exit interview was conducted. A Notice of site visit posted.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Jeremey McClainTELEPHONE: (916) 216-7801
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2019
LIC809 (FAS) - (06/04)
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