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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417528
Report Date: 08/07/2023
Date Signed: 08/08/2023 12:54:32 PM

Document Has Been Signed on 08/08/2023 12:54 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:KUTSEVOL FAMILY CHILD CAREFACILITY NUMBER:
197417528
ADMINISTRATOR:KUTSEVOL, ALINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 610-4645
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91423
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
08/07/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:ALINA KUTSEVOL/ANNA SMART- LicenseesTIME COMPLETED:
12:00 PM
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 08/07/2023 Licensing Program Analyst (LPA), Suzette Ornelas conducted an unannounced Annual Required Inspection and was met by Licensee, ALINA KUTSEVOL/ANNA SMART. Days and hours of operation are Monday through Friday 7:30a -6pm. Saturday and Sunday 9a-5p only if available.

LPA toured the home inside and outside and a census was taken. LPA observed 8 children and 2 adults. Current facility sketch reviewed and Licensee confirmed that the living room upon entry, dining room, children’s restroom located in the hallway of the home, playroom room and detached activity room is on limits and accessible to children in care. All other rooms are off-limits and made inaccessible by use of locked doors, baby a gate and supervision. The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. The First Aid kit was observed and complete. Per LIS the facility annual fees are current. The facility roster was observed, and current. There are age appropriate toys and napping equipment on the premises. The required fire extinguisher (2A 10BC), carbon monoxide detectors and smoke detectors are in operable condition. Licensee has posted as required the License, and all other required postings in a visible location.

There are no firearms or ammunition on the premises. There is no swimming pool on the premises. There is no fireplace located in the home.

There are currently 0 infants in care. Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained. LPA reviewed 5 children's records and observed records were complete.
SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023
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 3
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: KUTSEVOL FAMILY CHILD CARE
FACILITY NUMBER: 197417528
VISIT DATE: 08/07/2023
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
LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.

This report shall be made available to the public upon request. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensees, ALINA KUTSEVOL/ANNA SMART.
SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: KUTSEVOL FAMILY CHILD CARE
FACILITY NUMBER: 197417528
VISIT DATE: 08/07/2023
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
An emergency fire/disaster drill has been completed and documented within the last 6 months. Both Licensees pediatric CPR/First Aid is current. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles. Both Licensees have completed the Mandated Reporter Training within 2 years. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3