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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409296
Report Date: 08/03/2022
Date Signed: 08/03/2022 02:08:06 PM

Document Has Been Signed on 08/03/2022 02:08 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:GELFMAN, LARISAFACILITY NUMBER:
073409296
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
08/03/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Larisa GelfmanTIME COMPLETED:
03:00 PM
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On 8/3/22 at 1:00 pm Licensing Program Analyst (LPA), Monica Mathur conducted an announced Pre-licensing Inspection at Larisa Gelfman's home and met with Applicant, Larisa who has applied for a Small Family Child Care Home with a capacity of eight (8). Days and hours of operation will be Monday – Friday from 7 am - 6 pm.

Applicant completed 8-hour Preventative Health & Safety training, Nutrition and Lead Poisoning training, 8-hour Pediatric CPR & First Aid, has documentation for Measles, Pertussis, Influenza opt out statement for the current flu season. Applicant and adult living in the home have Criminal Record and Child Abuse Index Clearance and documentation for Tuberculosis (TB) clearance. Applicant has a child under age 18 living in the home. Applicant owns the home. LPA reminded that when care for more than six and up to eight is provided, Applicant must notify parents. Applicant will use the Affidavit Regarding Liability Insurance form to inform parents they do not carry a day care insurance. Applicant has a working telephone in the home.

Two story home comprises of:
Level 1: Living/Dining, Kitchen, Play Room, Nap Room, Bedroom, Bathroom, Storage room, Detached Garage
Level 2 (Off Limit): Bedroom, Bathroom, Office area

Areas to be used for day care: On Level 1 - Playroom, Nap room, Bathroom, Living/Dining area. Children will enter facility through main door (from left side deck), walk through the Living/ Dining area, into the Play room. They will access the outdoor play area the same way, out on the deck, walk down few steps to yard on the lower level.
Isolation Area: Living room
Off-Limit Areas: Bedroom downstairs, Kitchen, Storage room, entire Second floor
CONTINUED ON PAGE 2
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: GELFMAN, LARISA
FACILITY NUMBER: 073409296
VISIT DATE: 08/03/2022
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Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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

LPA discussed the safe sleep regulations with Applicant, and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant 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.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

Website links for provider resources:


Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov.
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important license-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
Applicant signed up for updates during inspection.

Facility is recommended for licensure EFFECTIVE 8/3/22, subject to approval by Management. Exit interview conducted and report was reviewed with the Applicant, Larisa Gelfman.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: GELFMAN, LARISA
FACILITY NUMBER: 073409296
VISIT DATE: 08/03/2022
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LPA toured the indoor space of the home. It is sanitary and orderly, with heating and ventilation for safety and comfort. Stairs to second floor are gated. There is a faux fireplace (ornamental) located in the Living Room and is screened. LPA observed fully charged fire extinguisher, working smoke, carbon monoxide detector. Medicines, cleaning products, sharp objects are stored inaccessible to children in cabinets with latches and locks. Door access to off limit areas are locked. LPA reminded that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family childcare homes. Applicant states there is 1 pet dog in the home and no arms and ammunition stored in the home.

Outdoor Space: LPA toured the outdoor areas. Children will be using the yard on the lower level accessible through a few steps down from the upper deck. The yard has fences on all sides. The property has a swimming pool area on the far right end of the backyard. It is inaccessible and fenced, locked gate which makes it completely inaccessible. The pool is under construction, a large earth pit with no water. Applicant states they do not plan to construct the pool anytime soon. LPA reminded when major construction is planned, she must inform CCLD.
ON LIMIT: Lower play area, Upper side deck (only walk through to access lower yard)
OFF LIMIT: Pool area, Deck in front of house, All pebbled areas in front and side.

Discipline policy was discussed, and Applicant states she will talk to the children as form of discipline. She understands that children's personal rights should not be violated and no corporal punishment. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries and requirements for assistant/substitute were also discussed. Fire drills must be practiced once every six months and documented. A Family Child Care Home packet was provided to and reviewed with the Applicant.

LPA reviewed with Applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

LPA discussed and reminded Applicant day care needs to be operated within the limitations and capacity of a Small Family Child Care Home with regards to ratios and that Licensee has to be present in the day care for 80% of the operation hours.
CONTINUED ON PAGE 3
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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