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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197411350
Report Date: 08/19/2024
Date Signed: 08/20/2024 08:47:42 AM

Document Has Been Signed on 08/20/2024 08:47 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:PASTUKHOV FAMILY CHILD CAREFACILITY NUMBER:
197411350
ADMINISTRATOR/
DIRECTOR:		PASTUKHOV, VIKTORFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 974-3143
CITY:WEST HOLLYWOODSTATE: CAZIP CODE:
90046
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 7DATE:
08/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Lilia Avagyan TIME VISIT/
INSPECTION COMPLETED:
02:28 PM
NARRATIVE
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On 8/19/2024, Licensing Program Analyst (LPA) Suzette Ornelas conducted an unannounced case management visit citing for a deficiency observed during an inspection. Upon arrival LPA Ornelas was greeted by Adult 1 (A1), Lilia Avagyan and observed 7 children and 2 adults.

Upon arrival, LPA observed through the open front window, 5 children being led into another room on the right side of the home by Adult 2 (A2), Alicia. LPA observed Adult 3 (A3), Iryna Briansteva supervising 2 infants. A1 stated that the 5 children went next door to their pertaining facility (197410759) and were only present at the facility for musical activity. Adult 4 (A4), Oksana Danylchenko, Licensee for facility #197410759, opened the door and stated that the children were only doing a musical activity and further stated that each facility has specific children enrolled.

LPA reviewed children's roster and children's files and confirmed that each child present had a file pertaining to them. LPA confirmed child's names by asking children present their names.

LPA conducted staff file reviews and guardian background checks and confirmed that A3 was not associated to the facility. A4 stated that staff had just begun working at the facility this year and although she does have criminal record clearance, she was not associated to the the facility. LPA was provided with a copy of the LIC9182 Criminal Background Clearance Transfer Request and a copy of ID. A3 working at the facility prior to Licensee requesting a transfer of a criminal record clearance as specified in Section 102370(j).

LPA advised S1 that all individuals prior to working residing, or volunteering in a licensed facility, shall have a criminal record clearance or a criminal record transfer. Due to Licensee not having A3 associated to the facility, this poses an immediate health and safety personal rights risk to children in care.

The following deficiency listed on the attached deficiency page is being cited in accordance with California Code of Regulations Title 22.
SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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 4
Document Has Been Signed on 08/20/2024 08:47 AM - It Cannot Be Edited


Created By: Suzette Ornelas On 08/19/2024 at 12:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: PASTUKHOV FAMILY CHILD CARE
FACILITY NUMBER: 197411350

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2024
Section Cited
CCR
102370(d)(2)

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102370(d)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility...Request a transfer of a criminal record clearance as specified in Section 102370(j)
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On 8/19/2024 LPA obtained a copy of the LIC9182 and A3's driver license. LPA verified that A3 was associated on 8/19/2024
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his requirment was not met as evidenced by. Upon arriving, LPA observed Adult 3 working at the facility prior to Licensee requesting a transfer of a criminal record clearance as specified in Section 102370(j). Adult 3 was not listed on the facility roster. This poses an immediate risk to children in care.
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Type B
09/02/2024
Section Cited
CCR102417(a)

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102417 Operation of a Family Child Care Home (a) The licensee shall be present in the home.... When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.
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LPA provided licensee with a copy ofthe regulation and will obtain signed decleration of understanding.
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This requirment was not met as evidenced by, Licensee operating hours are from 7a-6p and during todays inspection, licensee was not present between the hours of 10:30a and 2p. This poses a potential risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Raul Navarro
LICENSING EVALUATOR NAME:Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024


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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PASTUKHOV FAMILY CHILD CARE
FACILITY NUMBER: 197411350
VISIT DATE: 08/19/2024
NARRATIVE
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A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. A1 was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit.

The Notice of Site Visit must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview was conducted with A1.
SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/20/2024 08:47 AM - It Cannot Be Edited


Created By: Suzette Ornelas On 08/19/2024 at 01:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: PASTUKHOV FAMILY CHILD CARE
FACILITY NUMBER: 197411350

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2024
Section Cited
CCR
102421(a)

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102421 Child's Records

(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).
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Licensee will provide LPA with decleration explaining why children from facility next door (197410759) were present. Children present at the facility must have file available at their facility to view.
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This requirement is not met as evidence by, Licensee did not have file/forms of 5 children that were present for music class from facility nextdoor (197410759). This poses a potential risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Raul Navarro
LICENSING EVALUATOR NAME:Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024


LIC809 (FAS) - (06/04)
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