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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304204618
Report Date: 02/03/2026
Date Signed: 02/03/2026 11:51:37 AM

Document Has Been Signed on 02/03/2026 11:51 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:FOMENKO, CYNTHIAFACILITY NUMBER:
304204618
ADMINISTRATOR/
DIRECTOR:		FOMENKO, CYNTHIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 865-5438
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
02/03/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Fomenko, Cynthia (Licensee)TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 02/03/2026, an unannounced inspection was conducted at the facility by Licensing Program Analyst (LPA) Vivian Trinh. At 9:00 AM, observed licensee, caring for a total of 6, which included 2 infants, 4 preschoolers, were playing in the Living Room. The licensee stated that the total enrollment is 14, and the Licensee aware that they cannot exceed the capacity ratio of 14 children at any one time. The licensee was operating within the licensed capacity as specified on the license.

A review of the Facility Personnel Report Summary on this date, 02/03/2026, indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently, there are two (2) adults, including the licensee, and Zero (0) minor children living in the facility. Facility Day care hours are 7:30 am-5:30 pm, Monday through Friday.

During today’s inspection, the LPA and licensee toured the inside and outside areas of the facility, sketching LIC 999 as accessible to childcare children. This is a two story home with 3 bedrooms and 3 1/2 bathrooms. License has placed a safety gate at the bottom of the stairs leading to the 2nd floor, ensuring it is inaccessible to children in care. Off-limits areas are made inaccessible by means of baby gates or doorknobs or latches.

Licensee stated that OFF-LIMITS areas include: all bedrooms upstairs, 1 room on the end left hallway, garage, backyard, front yard, and storage. The licensee acknowledged that children may never enter these off-limit areas.

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NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Vivian Trinh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: FOMENKO, CYNTHIA
FACILITY NUMBER: 304204618
VISIT DATE: 02/03/2026
NARRATIVE
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INDOOR INSPECTION: The childcare area consists of the family room, the playroom located in the back of the home, and the bathroom located downstairs in the hallway. During today's inspection, each child was observed to have safe, healthful, and comfortable accommodations, furnishings, and equipment.

ON-SITE FOOD PREPARATION: The facility provides breakfast, lunch, and snacks to the children. At the time of inspection, food prep areas were clean and sanitary, and food was properly stored. Filtered drinking water is available to clients in care. The LPA observed that the facility’s floors, equipment, furniture, and clients’ bathrooms were clean and in good repair.

OUTDOOR INSPECTION: Licensee stated they do not use the backyard for outdoor play. There are no bodies of water on the premises.

The garage will not be used for day care. The Licensee stated the garage will be off-limits.

LPA discussed Assembly Bill 2866 regarding in-ground swimming pool safety requirements and provided licensee PIN 25-01-CCP Chaptered Legislation Affecting Childcare Facilities.

There are working carbon monoxide, smoke detectors, that should be type 2A-10BC, and fire extinguishers in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. No poisons or other items that could pose a danger to children were observed; if any were observed, they were locked or inaccessible. There is no fireplace. The home has age-appropriate toys for the children it serves. The licensee is aware that each FCCH shall conduct fire drills and disaster drills at least once every six months. A record review shows that the last drill was documented on 12/22/2025. LPA verified there is a working telephone service (cellular service), licensee was reminded that the childcare phone needs to remain in the childcare at all times. The licensee stated they do not use the backyard for outdoor play.

The licensee does have a current roster of children in care, of 5 children's records for the children present during the LPA inspection time.
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NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Vivian Trinh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: FOMENKO, CYNTHIA
FACILITY NUMBER: 304204618
VISIT DATE: 02/03/2026
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Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700), Immunization records, Affidavit Regarding Liability Insurance (LIC282), Consent for Emergency Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995A), and found to be in compliance. The licensee stated that there are 2 infants under 24 months enrolled in the childcare. LPA reviewed the LIC 9227 Individual Infant Sleeping Plan and napping log for infants.

The licensee's Pediatric CPR/First Aid certification expired 5/2026. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states that a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis and measles for the licensee was reviewed and in compliance.
Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training and to renew the training every two years. At 9:00 AM LPA, the Licensee failed to ensure that Staff 1 (S1) did not have the current mandated reporter training certificate, which had expired on 7/15/2025.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/.

The licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care for and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian Continued Page 4.
NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Vivian Trinh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: FOMENKO, CYNTHIA
FACILITY NUMBER: 304204618
VISIT DATE: 02/03/2026
NARRATIVE
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The CCLD website www.cdss.ca.gov/inforesources/community-care-licensing was provided to the licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

LPA discussed the safe sleep regulations with licensee Fomenko, Cynthia 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. LPA also informed licensee [facility representative] 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.

Licensee Fomenko, Cynthia 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.

The facility was not in compliance, and violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed, and cited at the time of the visit. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: Administration of Child Day Care Licensing HSC 1597.622(c) (see LIC 809D).

Licensee Fomenko, Cynthia 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.
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NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Vivian Trinh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: FOMENKO, CYNTHIA
FACILITY NUMBER: 304204618
VISIT DATE: 02/03/2026
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To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Exit interview conducted and report was reviewed with the licensee, Fomenko, Cynthia. A notice of site visit was given and must remain posted for 30 days. The Appeal Rights were explained. The licensee received a copy of the Appeal Rights

During the exit interview, the licensee, Fomenko, Cynthia, confirmed that there are no Registered Sex
Offenders living in the facility and LPA completed the RSO profile in FAS.

End of Report.
NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Vivian Trinh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/03/2026 11:51 AM - It Cannot Be Edited


Created By: Vivian Trinh On 02/03/2026 at 10:39 AM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: FOMENKO, CYNTHIA
FACILITY NUMBER: 304204618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, The licensee did not comply with the section cited above in. At 9:00 AM, LPA observed, the Licensee failed to ensure that Staff 1 (S1) did not have the current mandated reporter training certificate, which had expired on 7/15/2025, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
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Licensee stated will send proof of Mandated Reporter Training to LPA by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nguyen K Tran
NAME OF LICENSING PROGRAM MANAGER:
Vivian Trinh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2026


LIC809 (FAS) - (06/04)
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