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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625451
Report Date: 04/08/2024
Date Signed: 04/08/2024 03:56:06 PM

Document Has Been Signed on 04/08/2024 03:56 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:KONTSEMAL, ANASTASIIAFACILITY NUMBER:
343625451
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
04/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Anastasiia KontsemalTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst Erwina Pascual-Golamco and Loraine Perez (LPA) met with Licensee Anastasiia Kontsemal for the purpose of a case management inspection. The purpose of today's inspection was explained. LPAs observed 6 children in care with the licensee and 2 adult assistants that were not associated to the facility, LPA asked for staff files, and licensee stated she does not have the files for LPAs to review.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.


A civil penalty is being assessed in the amount of $100 for Clearance Transfer for 2 individuals.

Based on today's inspection, Title 22 deficiencies are being cited on the following LIC9099-D. Exit interview conducted and report was reviewed with Licensee. A notice of site visit was given and must remain posted for 30 days. Appeals right provided.

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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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Document Has Been Signed on 04/08/2024 03:56 PM - It Cannot Be Edited


Created By: Erwina Pascual-Golamco On 04/08/2024 at 02:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KONTSEMAL, ANASTASIIA
FACILITY NUMBER: 343625451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2024
Section Cited
CCR
102370(d)(2)

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102370 Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 102370(j)...This requirement is not met as evidenced by:
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Licensee stated she will associate adult assistants to her facility, and will email LPA documentation that she has transferred their clearance by 4PM POC due date.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as LPA observed 2 adult assistants were not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
04/22/2024
Section Cited
HSC1597.622(a)(2)

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ยง1597.622 Employees or volunteers at family day care home; immunization requirements; records; exemptions...(a)(2) If a person meets all other requirements for employment or volunteering, as applicable, but needs additional time to obtain and provide his or her immunization records, the person may be employed or volunteer conditionally for a maximum of 30 days upon signing and submitting a written statement attesting that he or she has been immunized as required.
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licensee stated she will complete required immunizations and all required documentation for adult assistants and will provide documentation and email to LPA by 4PM on POC due date.
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.This requirement is not met as evidenced by:
Licensee did not have required documentation for 2 staff for LPAs to check at time of LPA visit. Licensee showed documentation od CPR/FA for 1 staff.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Natalie Dunaway
LICENSING EVALUATOR NAME:Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024


LIC809 (FAS) - (06/04)
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