Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414107
Report Date: 11/04/2015
Date Signed: 11/04/2015 04:23:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:RYCZKOWSKA, ALEKSANDRA & RYCZKOWSKI, BOGDANFACILITY NUMBER:
434414107
ADMINISTRATOR:RYCZKOWSKA, ALEKSANDRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 280-8615
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:14CENSUS: 5DATE:
11/04/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:18 PM
MET WITH:AleksandraTIME COMPLETED:
04:40 PM
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An unannounced Annual / Random visit was made to the facility. Met with Aleksandra and her niece. Today, they were caring for 5 children, four of whom were infant. Observed children napping .
Aleksandra is the homeowner and resides in a single family home with her husband, son, daughter in law and her four grandchildren ages 10, 8, 6 and 3 y.o.

Off limit area are: entire upstairs, garage, gated section of the backyard and Aleksandra's living quarter( downstairs). Children have access to the living room and kitchen in the main house. The entrance to her day care is from side yard of the house.
Home has a right size fire extinguisher and workable smoke alarm.
Reviewed all required children and facility's forms which all were up to date.
Discussed regulations regarding Large Family Home. She stated that at this time she has total of 7 children enrolled in her program.
There are no bodies of water on the property.
Aleksandra states there are no firearm in the home.
Cleaning Solutions and medicines are kept inaccessible to children.
Home observed to be clean and orderly.
Children bring in their own snacks. She has one diabetic child. She monitor her insulin shot.
There is a working phone number and number is the same as application.
All cleaning solutions and medicines have stored out of the reach of the children.
She has an updated children's roster. Discussed Healthy beverage act. She serve water for children.
Aleksandra conducted her emergency drill on 06/01/2015..
Aleksandra has current pediatric 1st aid/CPR training valid until 9/13/2016.
Discussed regulations regarding Fingerprints and civil penalty associated to clearance. All adults residing and working with Aleksandra have all required clearances. She has total of 7 adults associated to her facility.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2015
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: RYCZKOWSKA, ALEKSANDRA & RYCZKOWSKI, BOGDAN
FACILITY NUMBER: 434414107
VISIT DATE: 11/04/2015
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Discussed regulation regarding fingerprint clearance and the fee associated to adult residing in the house without proper clearances. Applicable civil penalties for adults who are not fingerprinted prior to moving into the home or prior to having contact with the children was discussed ($100 per person, for up to 5 days Max of $500 & if cited again within 12 months Max. of $3000). To obtain copies of licensing forms/documents and Title 22 Regulations, visit the Department of Social Services website at www.ccld.ca.gov.
Discussed Zero Tolerance violation and civil penalty associated to the citation. Discussed Healthy beverage act.
Notice of site visit was posted and the Notice must be up for 30 days.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2015
LIC809 (FAS) - (06/04)
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