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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314042
Report Date: 06/06/2022
Date Signed: 06/20/2022 11:15:38 AM

Document Has Been Signed on 06/20/2022 11:15 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:BENSON, MARINA & LISNYAK, IRYNAFACILITY NUMBER:
304314042
ADMINISTRATOR:BENSON, M & LISNYSK, I.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 606-5814
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
06/06/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Applicant: Ms. Benson, Marina TIME COMPLETED:
12:30 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
Licensing Program Analyst (LPA) Desai, Ketki conducted an announced in-person Pre-Licensing inspection for a new Large Family Child Care home. LPA met with the applicant Ms. Benson, Marina who provided a tour of the new home. It is a Relocation. Ms. Benson has been a Family Child care provider since 2019.

A review of the Facility Personnel Report Summary indicates adult residents, who require caregiver background check clearances, transfers, exemptions have been obtained and they are cleared.
Applicant stated, she is not currently registered with any Resource Foster Care agency or holds a Resource foster parent license. Applicant was reminded if changes, to notify the licensing office.

The applicant is requesting a Large family childcare home license. Per applicant, operation hours will be Monday to Saturday 8:00 AM to 6:00 PM and care and supervision shall be provided to children ages 15 months to 10 years old (Infants to School age children).

All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a two story family home with 4 bedrooms, 3 full bathrooms, Office room, family room, living area, kitchen, backyard with two side yards, covered patio area and an attached garage.

Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone is the primary contact phone for Emergency use. Ventilation and heating. There is central air and heat in the home. Home has ceiling vents for air flow. The A/C unit is in the Left hand side yard .

Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The applicant states (that there are no poisons on the premises). Applicant was advised that any poisons must be locked with a key or combination lock.
(1)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: BENSON, MARINA & LISNYAK, IRYNA
FACILITY NUMBER: 304314042
VISIT DATE: 06/06/2022
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
Based on the Facility Sketch submitted, areas off limits to children and parents are: Applicant has designated the second level of the home as off-limits (3 bedrooms/ Office room and 2 full bathrooms) on the fist level, kitchen, attached garage and left hand side yard as off limit areas. Applicant has installed child safety gates on both the ends of the kitchen area making the kitchen completely inaccessible to children. There is a child safety gate installed at the end of the stairway making the second level of the home inaccessible to children. There is a Fire place in the day care room ( Family room) which is completely covered with a wooden plywood sheet and the TV is mounted on top of it. Garage door is in the laundry room with a double bolt locks. Left hand side yard is made inaccessible by blocking the side yard with a wooden bench making the side yard inaccessible to the children.

During the Pre-licensing inspection, LPA observed the designated off limits areas were closed and locked.

The applicant shall use the Cell phone for Day care activities and applicant was informed if a cell phone is used for child care, it must remain on the premises at all times during hours of operation. Applicant was informed and understands the home is to be free from smoking during hours of operation.


Applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

Areas Designated for Day care activities: Applicant has designated the first level of the home for Day care activities> Children shall enter the home through the right hand side yard wooden gate, which leads into the back yard area. This is the designated pick up and drop off area. The sliding door leads into the family room, designated Art room, living area & dining area are set up for additional day care activities. The Bedroom is called as a Den which is the designated napping room for the children. Designated day care bathroom is next to the bedroom.

The designated Day Care room has age appropriate furniture along with educational and play activities for children. Children shall nap in the Den room, on the cots, linens shall be provided by the applicant while blankets are brought from home and washed on a weekly basis by the applicant or parents.

Dining activities shall be held on the dining area adjoining the living area, applicant has placed an age appropriate table and chairs for the toddlers and preschool age children. Applicant shall provides Breakfast/ Lunch and PM snacks to the children, if lunch is brought from home, these containers shall be labelled with their names by the parents and stored accordingly. (2)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: BENSON, MARINA & LISNYAK, IRYNA
FACILITY NUMBER: 304314042
VISIT DATE: 06/06/2022
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
The bathroom is located next to the Den room, on the right side, it is easily accessible from the Day care room . Applicant has small step stool and toddler toilet seat for the younger toddlers. There is a cabinet under the sink, with paper products only. There is an additional exit door with two bolted locks in the bathroom. Applicant shall install an additional safety lock on the top making this door secured. The children's bathroom was observed to be safe and free of hazardous items.

Laundry room shall be used only by the staff to change the young toddlers by placing a changing pad on the floor. The cabinets on the top has additional diapers and wipes for the children.

Upon entrance through the designated main door of the home, applicant shall receive the children here, due to pandemic parents are encouraged to follow CDC guidelines, upon entrance temperatures shall be checked, hands shall be sanitized, before children are guided into the designated day care areas.

Applicant has set up a sanitizing station at the entrance door of the house, on a side table.

OUTDOOR PLAY AREA: Applicant has designated the covered patio area and the open back yard for outdoor activities. Covered patio area has concrete flooring. There are age appropriate outdoor toys arranged here along with educational items. Back yard is completed fenced with grass flooring. The covered patio area and back yard shall be accessed from the sliding door of the day care Art room

Per Applicant there are NO Firearms/ Weapons / Bodies of Water or Pets in the home.



The value on the 2A10 BC fire extinguisher indicates fully charged, as indicated on service tag observed. Smoke and carbon monoxide detectors were tested and are operable. Applicant has placed the Fire extinguisher on the side wall of the laundry room. Home has a dual Smoke & Carbon monoxide detector mounted on the ceiling of the living room, passage area and in each of the four bedrooms. Home also has a Fire Alarm system mounted as per the Fire Marshal requirements.

Applicant have completed the required Health and Safety training with Nutrition and Lead Poisoning component and Pediatric First Aid and CPR which is valid through 5/25/2024 There are first aid supplies available. Pending is the Mandated Reporter training.

(3) .
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: BENSON, MARINA & LISNYAK, IRYNA
FACILITY NUMBER: 304314042
VISIT DATE: 06/06/2022
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
The following was discussed with the applicant: In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR certification, TB clearance along with a valid criminal record clearance associated to the facility license.
Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
The fire extinguisher type 2A-10 BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

Fire and safety drills must be performed every six months and documented for review by the Department. Children and Staff records must be maintained and updated as needed and must be available for review by the Department.

No smoking, No Johnny jumpers, No Baby walkers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian ( Applicant has access to Guardian )


LPA discussed the following items with the applicant Ms. Benson, Marina during the Exit interview:

Criminal Record statement: Applicant Ms. Benson, Marina was reminded that all adults 18 and over living or working in the home, 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. (4)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: BENSON, MARINA & LISNYAK, IRYNA
FACILITY NUMBER: 304314042
VISIT DATE: 06/06/2022
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
Safe Sleep : LPA discussed the safe sleep regulations with applicant Ms. Benson, Marina & 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 of the applicant Ms. Benson, Marina 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 WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS: 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.

Review of records to be maintained : LPA reviewed with applicant Ms.Benson, Marina 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.

Subscribe to CCLD important information :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 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

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: BENSON, MARINA & LISNYAK, IRYNA
FACILITY NUMBER: 304314042
VISIT DATE: 06/06/2022
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
Exit interview conducted with the Applicant Ms. Benson, Marina this report was read to the applicant.

OTHER INFORMATION AND FORMS PROVIDED: Capacity Handout for a Large Family Child Care Home. LPA explained the age requirements for the enrolled children, for a Large family child care home and with an assistant provider may provide care for more than 12 and up to 14 children , when one child is enrolled in and attending Kindergarten (including transitional kindergarten) or elementary school, and another child is at least six years old and no more than three infants are in care.

LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment.

The facility at the time of Pre-licensing inspection is not in compliance for a (Large Family Child Care Home) with Title 22 Regulations.

Applicant needs to submit the following corrections

(1) Installation of a safety lock on the top of the bathroom exit door

(2) Submit the Mandated reporter Child Abuse training certificate.

License shall be issued upon receiving the listed corrections and upon management approval.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6