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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625666
Report Date: 07/23/2024
Date Signed: 07/23/2024 02:33:30 PM

Document Has Been Signed on 07/23/2024 02:33 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:KASHIRSKII, ANDREIFACILITY NUMBER:
343625666
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 1CENSUS: 0DATE:
07/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Andrei KashirskiiTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On July 23, 2023 at 12:10 PM, Licensing Program Analysts (LPAs) Tanya Washington and Michelle Perez arrived to the facility for an unannounced case management inspection and met with Licensee Andrei Kashirskii. Upon arrival, there were no daycare children or other adults present in the home.

LPAs learned of an incident that took place on July 15, 2024, during the incident police were called to assist. Licensee informed LPAs that there were no daycare children present during the incident and only his minor child was present. Licensee failed to report the incident as required per Title 22 Regulations.

LPAs also received photo evidence of eleven children being supervised by two adults on an unknown date. The Licensee stated that he is not sure of this time or who took the photo of children.

Title 22 deficiencies are cited on the subsequent page of this report (LIC809D). Licensee acknowledges, that for TYPE A DEFICIENCIES ONLY upon receipt, Licensee shall post LIC809-D with Type A deficiency for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the Licensee. This report was reviewed with the Licensee. Report, appeal rights, LIC9224, and notice of site visit were provided.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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 07/23/2024 02:33 PM - It Cannot Be Edited


Created By: Michelle Perez On 07/23/2024 at 02:02 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: KASHIRSKII, ANDREI
FACILITY NUMBER: 343625666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2024
Section Cited
CCR
102416.5(a)

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The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. This requirement is not met as evidenced: LPAs received photo evidence of eleven children inside the Licensee's facility. This is an
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Licensee will provide a letter of correction.

LPA will return to clear the citation and to make sure ratios are adhered to.
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immediate health and safety risk to the children 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:Keven Peters
LICENSING EVALUATOR NAME:Michelle Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/23/2024 02:33 PM - It Cannot Be Edited


Created By: Michelle Perez On 07/23/2024 at 02:07 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: KASHIRSKII, ANDREI
FACILITY NUMBER: 343625666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2024
Section Cited
CCR
102416.2(a)

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The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). This requirement is not met as evidenced: LPAs learned that police were called to assist with an
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Licensee stated he will submit a UIR to LPA and he understands that going forward all unusual incidents must be reported to CCL within 24 hours by phone and 7 days in written format (form LIC624B).
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incident that took place on July 15, 2024.
This is a potential risk to the health and safety of children 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:Keven Peters
LICENSING EVALUATOR NAME:Michelle Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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