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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624271
Report Date: 04/12/2022
Date Signed: 04/12/2022 11:54:39 AM

Document Has Been Signed on 04/12/2022 11:54 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:KURPIEWSKI, ERNESTINAFACILITY NUMBER:
343624271
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
04/12/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ernestina KurpiewskiTIME COMPLETED:
12:00 PM
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At 10:00 a.m. on Tuesday, April 12th, 2022, Licensing Program Analysts (LPAs) Karyn Guerra and Amanda Sutter met with Applicant, Ernestina (Lucy) Kurpiewski, for the purpose of a prelicensing inspection. Applicant guided LPAs on a tour of the home. The single story home consists of 3 bedrooms, 2 bathroom, living room, kitchen and garage. Off limits area will consist of the Kitchen/Dining room, Master Bedroom, Second Bedroom, garage, and side yard. Applicant understands that child care children must not enter these off limits areas. Hours of operation are 7:00 a.m.- 5:30 p.m., Monday thru Friday.

Applicant rents the home and has provided proof of control of property via a rental agreement. Applicant has completed the required Preventative Health and Safety course which includes 1 hour of nutrition and lead prevention training. CPR and First aid certification was verified and will expire on 3/2024. Mandated reporter training was verified and expires February 2023. LPA provided blank forms required for children's records including immunization card. LPA also provided the Parent's Rights form/poster, reviewed vaccination requirements for staff and children, and reviewed COVID-19 guidelines.

Backyard space is fenced. There are no bodies of water on the premises. Applicant understands 100% supervision shall be maintained in or around bodies of water, and in unfenced areas. Applicant stated that there are no weapons nor poisons in the home. Cleaning compounds, knives and medications are inaccessible to children.

LPA observed functioning smoke and carbon monoxide detectors, and a 2A10BC fire extinguisher that meets regulatory standards.

(report continued on 809-C)

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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: KURPIEWSKI, ERNESTINA
FACILITY NUMBER: 343624271
VISIT DATE: 04/12/2022
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Applicant understands that a current roster must be maintained and that a fire drill must be conducted and documented once every six months.

LPA reviewed updated safe sleep regulations with applicant. LPA observed a play yard at the facility. Applicant understands that there shall be one crib or play yard for each infant in care who is unable to climb out of a crib or play yard and an infant sleep plan form LIC9227 shall be kept on file for all infants under 12 months. Applicant understands that infant cribs or play yards shall be free of all loose articles and objects. Applicant understands that they shall physically check on a sleeping infant every 15 minutes and document.

Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. LPA explained to applicant that if they relocate and wants to continue to provide care, they must submit a change of location application and have the new home inspected.

Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within seven days to remain in compliance.

Applicant understands that if any changes are made to the off limits of the home; licensing must be notified and a safety inspection conducted prior to any child care children being able to have access to the area.

This facility evaluation report was reviewed and discussed with the applicant. Records, postings and reporting requirements were discussed. LIC311D was provided and discussed. Applicant was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

As of Tuesday, April 12th, 2022, facility is approved for a Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC809 (FAS) - (06/04)
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