Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623676
Report Date: 09/14/2020
Date Signed: 09/15/2020 11:40:08 AM

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:SMYSHKOVA, ANNAFACILITY NUMBER:
343623676
ADMINISTRATOR:SMYSHKOVA, ANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 949-6332
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:14CENSUS: 0DATE:
09/14/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Anna SmyshkovaTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Tanya Washington contacted Applicant Anna Smyshkova for the purpose of a scheduled announced pre-licensing/ change of location tele-inspection. Due to COVID19 pandemic, a tele- inspection is being conducted via Facetime. The applicant is currently licensed at facility #343622728. Applicant submitted an application for a large license and is currently pending approval from Sacramento County Department of Community Development Building Permits and Inspection. Applicant stated that she had her appointment with the inspector today, there were few things that needed to be corrected prior to re-inspection. During today's virtual inspection no children were present in the home. Applicant has moved most of the furniture, however the day-care area is not yet set up. All individuals subject to criminal background review have obtained a criminal record clearance. Applicant plan to operate Monday- Friday from 8 AM to 6 PM. Applicant owns the home and a copy of the mortgage statement has been requested.

A health and safety inspection was conducted inside and out. This is two story facility, the entire portion of the second floor will be inaccessible to children (second floor has 1 bedroom and one full bathroom), Applicant stated that this area is her master bedroom. The stairs leading to the second floor are closed off by a door. The first floor of the home has a separate entrance to Applicant's mothers living area, this area consists of (1 bedroom, 1 bathroom and a family room). Additionally, the first floor contains 2 bedrooms, 2 bathrooms, converted covered patio, family room and day-care room. The area used by children will be the day-care room with an attached "library room" and a bathroom also connected to the day-care room. The off-limit areas in the home will consist of the second floor, Applicant's mother's part of the home, Licensee's son's and daughter's rooms and fenced back portion of the yard which also includes the storage shed. Off-limits areas will remain inaccessible to children by closed doors and/or supervision.

Report continues on LIC809-C.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2020
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 3
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: SMYSHKOVA, ANNA
FACILITY NUMBER: 343623676
VISIT DATE: 09/14/2020
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The fireplace located in the family room is properly barricaded. Toxic and hazardous items are inaccessible to children and are stored out of children's reach. Sharp knifes are stored out of children's reach in the kitchen area. Medication is stored out of children's reach. A functioning smoke and carbon monoxide detector are functioning in the home. LPA observed a 2A10BC fire extinguisher in the kitchen, Applicant is required to install the fire extinguisher per fire inspector's request. Applicant is in the process of putting up required posters for FCCH.
Applicant's home has a tree house in the front yard, Applicant stated that she will provide 100% supervision to children when they will use the tree house. The front yard is fully fenced and that's where children will spend time outdoors.

Applicant Smyshkova has completed the required Preventative Health and Safety course, however due to recent law change she is required to take the "stand alone" Lead Prevention training through EMSA certified instructor, Applicant has signed up for the course. Applicant has a current EMSA certified CPR and First Aid card. Applicant stated there are no weapons in the home. There are no bodies of water on the premises. Applicant was encouraged to maintain supervision at all times. Type A/B citations and Immediate Civil Penalty regulation deficiencies were reviewed.

Incidental Medical Services (IMS) policy was discussed. 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


Continued on LIC809C
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2020
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: SMYSHKOVA, ANNA
FACILITY NUMBER: 343623676
VISIT DATE: 09/14/2020
NARRATIVE
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This facility evaluation report was reviewed and discussed with the Applicant. LIC 311D, records, postings, and reporting requirements were discussed. LPA discussed supervision, personal rights, criminal record clearances, ratios and capacity, and maintaining buildings and grounds. Applicant was encouraged to visit the Department's website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

Prior to licensure the following is required:
- Fire clearance
- Send photos of fully furnished rooms
- Send photos of required posters
- "Stand Alone" Lead Prevention course
- Copy of mortgage statement

Upon receipt of the above items a large provisional license will be grated. Upon completion of Lead Prevention course, Applicant will be granted a regular license.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2020
LIC809 (FAS) - (06/04)
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