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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409090
Report Date: 02/02/2022
Date Signed: 02/02/2022 04:26:12 PM

Document Has Been Signed on 02/02/2022 04:26 PM - 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:LEVINA, VALENTINAFACILITY NUMBER:
073409090
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 10CENSUS: 6DATE:
02/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Valentina LevinaTIME COMPLETED:
04:30 PM
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On 2/2/22 at 3;00 PM Licensing Program analyst (LPA) Monica Mathur conducted an unannounced Case Management inspection at Valentina Levina's family home. LPA explained the purpose of today's inspection. Present in the home were 6 day care children (preschool age), Licensee and Assistant.

Purpose of inspection is to ensure good standing and compliance of regulations cited on an unannounced annual inspection conducted on 10/13/21 where facility was cited two Type A deficiencies for Criminal Record Clearance and Out of Ratio.

All adults present today are fingerprint cleared and associated to the license, They are in ratio compliance today, LPA conducted a walk through indoor and outdoor, observed there was visual supervision of all children, all dangerous items were stored inaccessible to children and all files were complete and contained signed copies of Statement Acknowledging Receipt of Licensing Reports LIC9224 of report given on 10/13/21.

Licensee was reminded to make all doors/gates opening to off limit area of the residence inaccessible to children i.e install child proof or inaccessible locks and submit photos to CCL. Change the Emergency Disaster Plan to LIC610A for Family Childcare Homes.

No deficiencies were cited today. At 4:15 PM exit interview was conducted with Licensee, Valentina. A NOTICE OF SITE VISIT WAS ISSUED, TO BE POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2022
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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