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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618017
Report Date: 01/26/2023
Date Signed: 01/26/2023 03:57:50 PM

Document Has Been Signed on 01/26/2023 03:57 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: 10CENSUS: 7DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Lyubov SiumbeliTIME COMPLETED:
02:45 PM
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On January 26, 2023 at 1:45 PM, Licensing Program Analyst (LPA) Tanya Washington met with Licensee, Lyubov Siumbeli for an unannounced Required 1 year annual inspection.

LPA observed care and supervision of seven children, also present is Licensee's spouse Nicolai Siumbeli. Licensee stated there aren’t new residents in the home. All adult residents have criminal record clearances.

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.

LPA toured areas of the home accessible to the children. The off-limit areas of the home include garage and shed located in the backyard. Licensee understands that children may not have access to the off limit areas.

LPA observed current CPR/First Aid certificates for Lyubov and her spouse which expires 09/2023. LPA observed the following posted: a license, a Parents' Rights Poster and an Emergency Disaster Plan. LPA observed that licensee has current completion of AB1207 Mandated Reporter training which expires 03/16/2024. LPA provided Licensee with website: http://childcare.mandatedreporterca.com/ and reminded the licensee that the training must be completed once every two years. LPA reviewed children's records for completeness, as well as the client roster.

During the interior and exterior inspection:
LPA observed that hazardous items (detergents, cleaning compounds, medication, sharp utensils, and other items that could pose a danger to children in care) are properly stored out of children's reach. There is no fireplace in the home. LPA observed a working telephone in the home. Licensee stated that there are no weapons in the home. LPA observed a fire extinguisher which licensee stated was serviced within the last year. Carbon monoxide and smoke detectors were tested and observed to be functional.
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SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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 2
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: 01/26/2023
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No deficiencies were observed during today’s inspection.

This report was reviewed with licensee, and an exit interview was conducted.

A Notice of Site Visit was provided and should remain posted for 30 days.
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SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC809 (FAS) - (06/04)
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