214005611-7-29-2022-05-CC-HLEG-CGSW3Y-20220729165642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214005611
Report Date: 07/29/2022
Date Signed: 07/29/2022 04:56:47 PM

Document Has Been Signed on 07/29/2022 04:56 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	GONCHAROUK, IRINA		FACILITY NUMBER:	214005611
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	07/29/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	03:27 PM
MET WITH:	Irina Goncharouk		TIME COMPLETED:	04:50 PM

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On 7/29/2022, Licensing Program Analyst (LPA), Hanson Leong, conducted a scheduled, pre-licensing inspection with the applicant, Irina Goncharouk. Applicant requested to change her location from 4 Point San Pedro Rd, Unit 4, San Rafael, CA 94901. The applicant also requested an increase in capacity from eight to fourteen. LPA was granted entry by the applicant. LPA explained to the applicant about the purpose of the visit. All the facility's staff members have had their criminal background checks cleared by Guardian. Hours of operation are from Monday to Friday, 8:00 am to 5:00 pm.

Applicant rents the home. Before children enroll, the applicant states that she will purchase liability insurance for her home day care. Applicant plans to care for children ranging in age from ten months to 42 months.

Day care area(s): Side Entrance, Bedroom (Napping only), Living room, Kitchen/Dining Area, Backyard and Bathroom #1 and Bathroom #2

Off-limits area(s): Closets. Applicant is aware off-limits areas are not to be used during business hours

Both LPA and the Applicant conducted a health and safety inspection of the home. LPA found the home to be clean and safe, with a functioning smoke and carbon monoxide detector, and a fully charged fire extinguisher. The applicant has a fully stocked First Aid kit as well as a thermometer. There is no fireplace in the home, nor are there any bodies of water. The applicant has garbage cans with tightly fitting covered lids. The children in care have access to age-appropriate toys and equipment at the home. LPA reminded the applicant that baby walkers, bouncers, jumpers, and similar items should not be used for children in care.

Applicant has a designated cell phone and is aware that it must be kept in the home during day care hours. According to the applicant, there are no firearms or weapons in the home. The bedroom will be the isolation area for a sick child. All hazardous materials and toxins are kept out of children's reach and are inaccessible. Applicant intends to serve food to the children. ***See Page 2 for continuation***

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022

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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GONCHAROUK, IRINA	FACILITY NUMBER: 214005611
	VISIT DATE: 07/29/2022

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Continued, Page 2
The applicant will provide cribs and resting mats for the children while they are napping.

LPA reminded the applicant that the CPR and First Aid training must be renewed every two years. Applicant has proof of immunization and has completed the Mandatory Reporter Training. LPA reminded that the Mandated Reporter Training must be renewed every two years.

LPA informed the applicant that emergency disaster drills should be conducted at least once every six months and that the date and time of the drill should be recorded. If applicant provides care to the seventh and eighth child, who must be school aged, parent notification and landlord consent is required. The following is required to be posted in an accessible location in view of parents: Emergency Disaster Plan (LIC 610), Parent's Rights (LIC 995A), and License (once received).

LPAs discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPAs 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

Incidental Medical Services (IMS) policy was discussed. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

A packet of forms pertaining to the children’s files and facility files were reviewed and discussed. Applicant was advised all assistants, volunteers, frequent visitors or adults living in the home, over the age of 18 must be fingerprint cleared, associated to the home and have proof of immunization, prior to having any contact with the children in care. Failure to do so could result in an immediate civil penalty of $100 per person, each day. ***See Page 3 for continuation***

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022

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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GONCHAROUK, IRINA	FACILITY NUMBER: 214005611
	VISIT DATE: 07/29/2022

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Following the pre-licensing inspection, LPA will recommend a Small Family Day Care Home license for the applicant. The applicant's new license will take effect on 7/29/2022.

Applicant was advised to contact San Bruno Regional Office for concerns or questions. Desk Duty is available Mon-Fri, 8:00am to 5:00pm at (650) 266-8800. Forms and regulations are made available at www.cdss.ca.gov/inforesources/Community-Care-Licensing.

A copy of the report was provided to the applicant

An exit interview was conducted, and the report was reviewed with the applicant, Irina Goncharouk

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022

LIC809 (FAS) - (06/04)

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