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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618017
Report Date: 02/23/2022
Date Signed: 02/23/2022 03:54:55 PM

Document Has Been Signed on 02/23/2022 03:54 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:SIUMBELI, LYUBOVFACILITY NUMBER:
343618017
ADMINISTRATOR:SIUMBELI, LYUBOVFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 613-4612
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Lyubov SiumbeliTIME COMPLETED:
02:30 PM
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On Wednesday, February 23, 2022, at 12:50 PM, Licensing Program Analyst (LPA) Tanya Washington conducted an unannounced Required 1 year annual inspection and met with Licensee, Lyubov Siumbeli. LPA observed care and supervision of nine preschool age children supervised by Licensee and her spouse, Nicolai Siumbeli. The off-limit areas include: garage and shed in the backyard. Licensee acknowledged that children may never enter these off-limits area. Licensee stated there are no new residents in the home since licensure. The hours of operation are Monday through Friday from 6 AM to 7 PM.

LPA observed current CPR/First Aid certificates for Licensee and her spouse. Licensee's expires 09/2023, Nicolai's expires 03/2023. LPA reviewed six children’s files. LPA observed that there were no hazardous items accessible to children. There is no fireplace in the home. LPA observed that cleaning materials were inaccessible. Fire extinguisher, smoke detector, and carbon monoxide detector meet regulation. Toys appear to be safe. There are no bodies of water or weapons on the premises. LPA discussed current COVID guidelines with Licensee.

LPA observed a current fire drill log and children’s roster. Licensee's Mandated Reporter training expires on 10/27/2022, she has taken the course through Child Action.
Licensee 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.

REPORT CONTINUED ON NEXT PAGE

SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: SIUMBELI, LYUBOV
FACILITY NUMBER: 343618017
VISIT DATE: 02/23/2022
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This facility does not currently provide Incidental Medical Services- IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.

Licensee stated that she currently doesn't have any children under two years old in her child care.
LPA discussed the safe sleep regulations with licensee 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 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.

LPA checked facilities fees and confirmed that it is up to date.



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.

In the areas that were evaluated, no Tittle 22 deficiencies were observed. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Lyubov Siumbeli.

SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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