Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414107
Report Date: 07/12/2018
Date Signed: 07/12/2018 04:24:51 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: 7DATE:
07/12/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Aleksandra RyczkowskiTIME COMPLETED:
04:30 PM
NARRATIVE
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LPA Deanna Villagrana met with licensee Aleksandra Ryczkowski for an unannounced annual/random inspection. LPA explained the nature of today’s inspection to her. Present were licensee and licensee's assistant Krystyna Herman in the day care area. Present in the main home was licensee's daughter in law and 4 grandchildren (13,11,9 and 6) Days and hours of operation are Monday to Friday, 8:00am to 5:30pm. The adults that reside in the home are licensee, her husband, adult son, daughter in law and 4 grandchildren.

A review of staff records on 07/09/2018 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee understands upon notice of the Department to remove an individual from the home, or to exclude an individual from the home, the licensee shall immediately remove the individual and prevents them from returning to the home or having contact with children in care.

LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children. LPA observed a fully charged 3A40BC fire extinguisher. LPA observed a working smoke detector and a working carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas in the main house: four upstairs bedrooms, three bathrooms, laundry room and downstairs one bedroom, two bathrooms rooms and attached garage. There are no bodies of water. Backyard is fenced. Off limits outdoor: fenced off area from the day care room. Licensee states she only has one fish in the office.

LPA observed licensee and her assistant have current CPR and First Aid certifications expiring 09/2018. LPA observed Krystyna did not have a current TB test on file. LPA observed licensee and her assistant have not completed Mandated Reporter training.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2018
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 4
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2018
Section Cited
CCR
102418(g)
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102418(g) Immunization. Licensee shall document and maintain each child’s immunization's as long as the child is enrolled.

LPA observed child 2,3,4,5 and 7 immunization's are missing are need to be updated.
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Licensee will submit current immunization's for children to CCLD by POC date.
Type B
08/13/2018
Section Cited
CCR
102419(d)
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License provides the child's parent or representative with a copy of the Family Child Care Home Notification of Parents' Rights.

Child 7 is missing LIC995A.
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Licensee will forward a copy to CCLD by POC date.
Type B
08/13/2018
Section Cited
HSC
1597.622(a)(1)
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1597.622 (a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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Licensee will forward a copy of current immunization's for herself and her assistant to CCLD by POC date.
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LPA discussed SB792 Immunization Requirements and observed licensee's and her assistant's did not have immunization's against pertussis, influenza and measles on file.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2018
LIC809 (FAS) - (06/04)
Page: 3 of 4
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2018
Section Cited
CCR
102369(b)(9)
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102369(b)(9) Application for License. Licensees and any adult in the home, shall provide evidence of a current tuberculosis clearance, performed and signed by a physician not more than one year prior to or seven days after first day of employment. LPA observed Krystyna did not have a current TB test on file.
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Licensee will submit a current TB test for Krystyna to CCLD by POC date.
Type B
08/13/2018
Section Cited
HSC
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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete
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Licensee will submit a copy of certificates indicating Mandated Reporter training was completed to CCLD. by POC date.
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renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.
LPA observed licensee and her assistant have not completed Mandated Reporter training.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2018
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: 07/12/2018
NARRATIVE
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LPA observed a current roster of the children and a fire and disaster drill log which was last completed on 04/03/2018. LPA reviewed seven children's files. LPA observed child 2,3,4,5 and 7 immunization's are missing are need to be updated. Child 7 is missing LIC995A. Licensee states day care is not insured. LPA observed LIC282 in each child's file. LPA discussed SB792 Immunization Requirements and observed licensee's and her assistant's did not have immunization's against pertussis, influenza and measles on file.
Supervision of children was discussed with licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed Zero Tolerance with $500 immediate civil penalty. An ongoing $100 per day per violation continues until the violation(s) is corrected. LPA discussed the requirements of AB633 to licensee and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and licensee understands the requirements. Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

The following deficiencies were cited.

Notice of site visit was issued and must be posted for 30 days.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2018
LIC809 (FAS) - (06/04)
Page: 2 of 4