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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343626303
Report Date: 11/19/2024
Date Signed: 11/19/2024 03:00:49 PM

Document Has Been Signed on 11/19/2024 03:00 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:KOSTRYTSYA, NADIYAFACILITY NUMBER:
343626303
ADMINISTRATOR/
DIRECTOR:		KOSTRYTYSA, NADIYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 802-9909
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
11/19/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Nadiya KostrytsyaTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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This is a Change of Location from previous facility number 343625289

Licensing Program Analyst (LPA) Erwina Pascual-Golamco met with Applicant Nadiya Kostrytsya, for the purpose of a change of location inspection. Fire Clearance was granted on 10/30/24. All individuals subject to criminal background review have obtained a criminal record clearance. Applicant plans to operate Monday to Friday 6AM to 11PM.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

The applicant provided proof of control of property. Because the applicant, rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

A health and safety inspection were conducted inside and out. This facility is a one story home. The home has a Daycare area, dining area, kitchen, three bedrooms, one bathroom, and garage. The off-limit areas will be: as stated in STD 850: Bedroom#3 and Garage. Applicant did not add any other off limit areas. Off-limit areas will remain inaccessible to children by closed doors and/or supervision. Toxic and hazardous items are inaccessible to children and will be stored on the top shelf of kitchen cabinet. Continued on LIC809-C...

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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: KOSTRYTSYA, NADIYA
FACILITY NUMBER: 343626303
VISIT DATE: 11/19/2024
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Functioning smoke and carbon monoxide detectors and 2A-10-BC fire extinguisher were observed in the home. LPA received EMSA certificate for Preventative Health, Safety, Nutrition, and Lead Poisoning Class training, Applicant's EMSA Pediatric CPR and First Aid training is valid until 08/26 and Mandated Reporter Training (MRT) is valid until 05/25. Applicant understands both Pediatric CPR, First Aid training and MRT Training must be renewed every two years. Applicant stated that there are no weapons or firearms in the home. Backyard is fenced, supervision was discussed, and applicant understands that children must be 100% supervised in unfenced yards. Immediate Civil Penalty regulation and deficiencies were reviewed. LPA did not observe bodies of water on the premises.

Incidental Medical Services (IMS) was discussed with Applicant. 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 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: http://www.ada.gov/childqanda.htm

LPA consulted applicant regarding the following topics; new upcoming regulations, Type A vs. Type B deficiencies, complaints, LPA’s right to interview children without parental consent, civil penalties, incidental medical services, placement of detergents, poisons and medicines, announced vs. unannounced inspections, posting requirements, unusual incident reports, On-limits vs. Off-limit areas, licensing file management, fire drills, 80% supervision, 100% supervision, fingerprint clearances, advertising, mandated reporting and best practices.



LPA consulted the applicant regarding personal rights. Applicant understands that corporal, physical and/or unusual forms of punishment is never allowed toward day care children or their own children during day care hours.
Continued on LIC809-C...
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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: KOSTRYTSYA, NADIYA
FACILITY NUMBER: 343626303
VISIT DATE: 11/19/2024
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LPA discussed the safe sleep regulations with applicant 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 applicant 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.

LPA reviewed with applicant the LIC311D, Forms/Records to Keep in Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. LPA advised Applicant to sign up for the quarterly updates provided by the Childcare Advocates Program. To receive important license related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication. Applicant is subscribed as of today.

Applicant was encouraged to visit the department website at WWW.CDSS.CA.GOV for information regarding childcare updates, forms, self-assessment guides, regulations and legislation pertaining to family childcare homes. LPA advised licensee of their responsibility to stay current regarding new regulations.

On this date, 06/12/24, the California Attorney General - Megan's Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.
Continued on LIC809-C...
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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: KOSTRYTSYA, NADIYA
FACILITY NUMBER: 343626303
VISIT DATE: 11/19/2024
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Effective today 11/19/2024, licensed for Large Family Childcare Home.

Facility is approved for a Large Family Child Care Licensed to serve 12 children (when there is an assistant present) with no more than 4 infants, or maximum capacity of 14 children when 1 child is enrolled in Transitional Kindergarten or above and 1 child at least age 6 with a maximum of 3 infants. Without assistant, the ratios revert to those for small family child care home. Exit interview conducted.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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