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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415167
Report Date: 03/09/2022
Date Signed: 03/09/2022 11:29:42 AM

Document Has Been Signed on 03/09/2022 11:29 AM - It Cannot Be Edited

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:SUPRYADKINA, ELENAFACILITY NUMBER:
434415167
ADMINISTRATOR:SUPRYADKINA, ELENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 271-2934
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:04 AM
MET WITH:Elena SupryandinkaTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Pete Hernandez conducted an unannounced Required 1 Year inspection at the home today. LPA met with Elena Supryadkina, Licensee, and explained the nature of today's visit. Also present were assistant Tetiana Stetsiuk. and tenant James Venzon. There were 10 children present at the time of LPA's Inspection: 2 Infants and 8 preschoolers. Hours are Monday through Friday from 8:30 AM to 6:30 PM. Licensee resides in the home with her tenant James Venzon.

LPA toured the indoor and outdoor areas. Off limit areas inside the home: entire upstairs, entire basement and kitchen. Off limit areas outside the home: Back yard, outside kitchen, outside fire place, pool. The exception is however; the detached cottage on other side of the back yard fence and the right side of the home received a fire clearance as a play area. Fire drills are conducted are every 6 months and logged. Licensee does have a current childrens roster and provided a copy to the LPA. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is orderly, and safe for the day care children.
LPA observed a fully charged 3A40BC fire extinguisher. There are working smoke & carbon monoxide detectors in the home with fire pull stations. LPA observed a swimming pool on property and LPA verified that the fitted power cover is locked and able to hold the weight of an adult. Licensee understands that all pools, spas, hot tubs, fish ponds, or similar bodies of water shall be covered or fenced as specified in title 22 regulations to be inaccessible to children. Licensee states that there are no weapons or firearms in the home. All detergents, cleaning compounds, other similar items and poisons are in the shed or out of reach, and are inaccessible to children. LPA reviewed the files of 10 enrolled children and 2 Staff including the Licensee. All required documentation was in the files Except 1 staff file missing LIC503 and vaccination records.
REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 03/09/2022:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SUPRYADKINA, ELENA
FACILITY NUMBER: 434415167
VISIT DATE: 03/09/2022
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Incidental Medical Services (IMS) policy was discussed. When any IMS is provided, an updated Plan of Operation that includes 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

A review of staff records today indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12- month period

Supervision of children was discussed with the Licensee. Licensee understands that she must be present in the home at least 80 percent of the hours the day care is in operation and ensure that the children are supervised at all times. The Licensee understands her capacity options. The Licensee states that she does not transport children and understands that children cannot be left in parked vehicles unattended at any time. Licensee understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick child, requirements for reporting suspected child abuse, unusual incidents/injuries, heat-related illnesses, and requirements for assistant/substitute were also discussed.
LPA informed Licensee that Licensing forms and Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #3 - REPORT DATED 03/09/2022:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
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: SUPRYADKINA, ELENA
FACILITY NUMBER: 434415167
VISIT DATE: 03/09/2022
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Licensee has a current CPR and First Aid card that expires on 7/2023. Her Assistant Tetiana's expires 2/2024.

Licensee has a current Mandated Reporter Certificate. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed at www.mandatedreporterca.com.

LPA discussed the Individual Infant Sleeping Plan form 9227. Licensee already uses this form.

Website for resource information: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates
LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list, childcareadvocatesprogram@dss.ca.gov

Type A language: Upon the issuance of Type A citations, a copy of the Facility Evaluation Report LIC809D has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with the licensee. A copy of this report was discussed and left with the Licensee, Elena Supryadkina, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC809 (FAS) - (06/04)
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