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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624271
Report Date: 04/27/2023
Date Signed: 04/27/2023 01:12:41 PM

Document Has Been Signed on 04/27/2023 01:12 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:KURPIEWSKI, ERNESTINAFACILITY NUMBER:
343624271
ADMINISTRATOR:KURPIEWSKI, ERNESTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(279) 345-0897
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ernestina KurpiewskiTIME COMPLETED:
01:30 PM
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On April 27, 2023 at approximately 12:30 PM, Licensing Program Analyst (LPA) Josiah Gathing met with licensee Ernestina Kurpiewski for the purpose of a required annual inspection. The facility days and hours of operation are Monday – Friday 7:00 AM to 5:30 PM. During today’s visit, LPA observed 4 infants and one preschool age child supervised by the licensee and assistant. All individuals subject to criminal background review have obtained a criminal record clearance.

A health and safety evaluation was conducted in all areas accessible to children. Off-limits areas of the home include: Both bedrooms, the garage, and the fenced side yard area in the back yard. LPA observed a full 2A10BC fire extinguisher, first aid kit, and functioning smoke and carbon monoxide detectors in the home. Per licensee, there are no weapons or poisons in the home. LPA observed required posted documents.

During file review, LPA observed all necessary Children’s documents. LPA observed the completed children's roster and fire drill log last updated March 20, 2023. LPA observed a CPR/First Aid certificate which will expire March 8, 2024.

Incidental Medical Services (IMS) policy was discussed. 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 followinginformation regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA available at: http://wwwada.gov/childqanda.htm

CONTINUED ON LIC809-C…

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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: 04/27/2023
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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 discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at http://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.

A notice of site visit was given and must remain posted for 30 days. Exit interview was conducted and report was reviewed with the Licensee, Ernestina Kerpiewski. This report and appeal rights were printed and provided to the Licensee.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC809 (FAS) - (06/04)
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