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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013416145
Report Date: 01/19/2023
Date Signed: 01/19/2023 11:58:26 AM

Document Has Been Signed on 01/19/2023 11:58 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:PRYSZCZUK, LUISAFACILITY NUMBER:
013416145
ADMINISTRATOR:PRYSZCZUK, LUISAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 828-4822
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 10DATE:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Luisa PryszczukTIME COMPLETED:
11:56 AM
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On 1/19/2023 at 9:57am Licensing Program Analyst (LPA) Morgan Pringle met with Luisa Pryszczuk for an Unannounced Annual Inspection. Present during the inspection was the Licensee, her two (2) helpers, L. Kozaczuk and G. Bejarano, four (4) infants and six (6) preschool age children. Licensee’s home was toured for a health and safety inspection. The facility operates from 8:00am – 5:00pm, Monday - Friday.

ON LIMITS AREA: Kitchen, Family Room, Bedroom 1, Bedroom 2, Hallway Bathroom and


Backyard
OFF LIMITS AREA: Bedroom 3 with attached Bathroom and Garage
ISOLATION AREA: Kitchen

Licensee requests to add Bedroom 2 as an on-limits area for new infants while they are sleeping and transitioning into the family childcare home. LPA inspected the bedroom and has approved the addition. A new facility sketch was created and given to LPA during the inspection.

The facility is a single-story home rented by the Licensee. The inside of the home was observed to be neat, clean with ample age appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. Licensee provides all food for the children that is properly stored and maintained. All food that may be brought from the children’s home will be properly labeled and stored. Licensee stated that are no firearms and one (1) small dog in the home.

Continued on LIC809-C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: PRYSZCZUK, LUISA
FACILITY NUMBER: 013416145
VISIT DATE: 01/19/2023
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The home has one (1) fully charged 2A10BC fire extinguisher in the kitchen. There is one (1) working smoke detector in bedroom 1, bedroom 2 and in front of the bathroom in the hallway. There is one (1) carbon monoxide detector in the hallway above the changing table. The home is equipped with central heat and plenty of windows for proper ventilation. The fireplace in the family room is blocked by furniture making it inaccessible to the children in care. LPA did not observe any bodies of water in or around the home that could be a potential danger to the children in care. The backyard is fully fenced, clean and well maintained with ample age appropriate materials for the children.

Licensee is operating within their licensed capacity and is in ratio. Licensee’s Health and Safety training has been completed and Pediatric CPR and First Aid training is complete with an expiration date of 3/1/2023. Licensee’s Mandated Reporter training is complete and expires on 8/2/2023. LPA obtained the fire/disaster drill log. Log is complete with the last drill completed 9/12/2022. All required forms are posted and visible for public view in the entry way of the home. LPA obtained a sample of the children’s files, the two (2) helpers files and the facility roster. All files were complete.

No deficiencies were cited during the inspection.

Licensee was reminded that California Law requires Licensee to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com.



Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

Continued on LIC809-C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: PRYSZCZUK, LUISA
FACILITY NUMBER: 013416145
VISIT DATE: 01/19/2023
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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.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

A notice of site visit was given and must remain posted for 30 days.


Exit interview conducted and report was reviewed with Licensee Luisa Pryszczuk.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC809 (FAS) - (06/04)
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