<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700238
Report Date: 05/12/2021
Date Signed: 05/12/2021 10:43:52 AM

Document Has Been Signed on 05/12/2021 10:43 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:CHELAKHSAEVA, EMMAFACILITY NUMBER:
015700238
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/12/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Emma ChelakhsaevaTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/12/21 at 9:32am, Licensing Program Analyst Briana Plumboy, met with applicant Emma Chelakhsaeva for an ANNOUNCED PRE LICENSING INSPECTION. Present for this visit was licensees daughter Angelina Chelakhsaeva. The home was toured to conduct a Health and Safety Inspection. Emma Chelakhsaeva plans to operate the facility Monday through Friday from 7:00am until 6:00pm.
The home is single story. The home consists of a laundry room, 3 bedrooms, dining room, a master bedroom with bathroom, a living room, and a hallway bathroom. The home is neat and clean with heating and ventilation for safety and comfort. The OFF LIMIT AREAS are the first bedroom on the right side of the hallway, laundry room, and master bedroom with master bathroom which will be inaccessible by closed and/or locked doors and visual supervision. The ON LIMIT AREAS are the hallway bathroom, the last bedrooms on the left and right side of the hallway, the dining room, and the living room. The ISOLATION AREA will be the bedroom at the end of the hallway on the right. Outdoor play area will be in the fenced backyard. The left and right sides of the home in the backyard are off limits to children in care and have gates to prevent access to them. The outdoor play area is free from defects or dangerous conditions during today's inspection. There is a deck/patio are which is on limits to children in care, then 2 steps down which lead to the second play yard. There is also a pull out shade on the deck/patio area. There are ample age appropriate toys that are safe and appeared to be clean. There are no pools, hot tubs or any other bodies of water on the premises. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today.
The home has 2 fully charged 3A40BC fire extinguishers, working combined smoke and carbon monoxide detectors, working telephone, and First Aid Kit. The applicant’s Health and Safety training is completed and CPR and First Aid certificate is current and expires 4/11/23. The applicant completed and received a certificate in mandated reporter training on 4/23/21. The applicant is in compliance with new immunization law which pertains to day care providers. There are floor heaters which get hot to touch and are covered to prevent access to children in care. Per applicant, there are no firearms in the home. A copy of the lease was reviewed and shows control of property.

See 809-C for continuance
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2021
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 2
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: CHELAKHSAEVA, EMMA
FACILITY NUMBER: 015700238
VISIT DATE: 05/12/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The applicant is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. Also, any adults moving into the home must be reported to Community Care Licensing prior to them moving in and all requirements must be met before the person lives in the facility.

California Law requires Family Child Care Home licensees 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 electronic mail. Roster of the children must be properly maintained and fire/disaster drill every six months must be documented.

The applicant was also reminded that baby bouncers, exersaucers, johnny jumpers and similar items are not allowed in licensed day care.

For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list



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

Applicant is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Applicant was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov



This home is recommended for licensing on 5/12/21. This report shall remain on file for 3 years. Exit interview conducted applicant.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2