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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625451
Report Date: 04/29/2024
Date Signed: 04/29/2024 02:05:07 PM

Document Has Been Signed on 04/29/2024 02:05 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: 4DATE:
04/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Anastasiia KontsemalTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst Erwina Pascual-Golamco and Jennifer Velasco (LPA) met with Licensee Anastasiia Kontsemal for the purpose of a case management inspection. The purpose of today's inspection was explained.

LPAs arrived at the facility at 11:10AM, LPAs observed 3 children in care with the only adult in the facility and licensee was not present. LPA observed adult and children were in the backyard, and another infant was sleeping inside the facility with door closed. Adult called Licensee to inform that LPA is at the facility, and Licensee arrived at 11:35AM. LPA determined and Licensee confirmed that adult assistant who was left with 4 children in care have not obtained a California criminal record clearance or exemption and did not have Pediatric First Aid/CPR certification.

A civil penalty is being assessed in the amount of $100 for Caregiver Background Check.

Licensee was informed that this report dated 04/29/24 documents two Type A citations. Title 22 Deficiencies are issued on the attached LIC9099-D page. Licensee shall provide a copy of this licensing report to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. Exit interview was conducted with Licensee, appeal rights were provided, and notice of site visit was given to Licensee, who will post it where visible to parents/guardians for 30 days. A signed Acknowledgement of Receipt of the Licensing Report (LIC 9224) must be placed in the child's file for verification.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2024
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 04/29/2024 02:05 PM - It Cannot Be Edited


Created By: Erwina Pascual-Golamco On 04/29/2024 at 12:27 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: 04/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2024
Section Cited
CCR
102370(d)(1)

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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:(1)Obtain a California clearance or a criminal record exemption as required by the Department
This requirement is not met as evidenced by:
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Licensee confirmed that adult will obtain criminal record clearance or exemption by 04/30/24, and that adult will not be in the facility and around children in care during operating hours until the clearance has been approved. LPAs observed uncleared adult left the facility during visit.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as LPA observed one uncleared adult at the facility during hours of operation which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
04/30/2024
Section Cited
CCR102425(j)(5)

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102425 Infant Safe Sleep
(j) The provider shall supervise infants while they are sleeping and adhere to the following requirements:
5) If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.
This requirement is not met as evidenced by:
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LPA asked adult assistant to open door to the room where infant was sleeping, and Licensee stated proper training will be provided and that door shall remain open to where infant is sleeping and provider will be stationed near sleeping infant. LPA will conduct a Plan of Correction visit.
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Based on observation and interview, the licensee did not comply with the section cited above as LPA observed one infant asleep with door closed and adult at the facility was in backyard with other children at play, which poses an immediate health, safety or personal rights risk to persons in care.
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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: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/29/2024 02:05 PM - It Cannot Be Edited


Created By: Erwina Pascual-Golamco On 04/29/2024 at 12:54 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: 04/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2024
Section Cited
CCR
102416(c)

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102416 Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
This requirement is not met as evidenced by:
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Licensee stated that no adult assistant without current CPR will be left alone with children, and that licensee will email by 4PM on POC due date the required personnel documents and Pediatric CPR/First Aid certificate to LPA.
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Based on observation and interview, LPA determined and Licensee confirmed that adult assistant who was left with children today, did not have Pediatric First Aid/CPR certification, which poses an immediate health, safety or personal rights risk to persons in care.
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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: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024


LIC809 (FAS) - (06/04)
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