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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624271
Report Date: 05/14/2024
Date Signed: 05/14/2024 02:13:42 PM

Document Has Been Signed on 05/14/2024 02:13 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KURPIEWSKI, ERNESTINAFACILITY NUMBER:
343624271
ADMINISTRATOR/
DIRECTOR:		KURPIEWSKI, ERNESTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(279) 345-0897
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
05/14/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Ernestina KurpiewskiTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On May 14, 2024 at approximately 1:25 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 three infants and nine 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 January 14, 2024. LPA observed a CPR/First Aid certificate which will expire March 30, 2026.

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: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KURPIEWSKI, ERNESTINA
FACILITY NUMBER: 343624271
VISIT DATE: 05/14/2024
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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.

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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee Ernestina Kurpiewski, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Ernestina Kurpiewski.

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

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC809 (FAS) - (06/04)
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