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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435700321
Report Date: 08/27/2021
Date Signed: 08/27/2021 12:06:42 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/27/2021 12:06 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:MISHYNA, HULIZARFACILITY NUMBER:
435700321
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
08/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Hulizar MishynaTIME COMPLETED:
12:04 PM
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On 8/27/2021 at 10:25am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Hulizar Mishyna for an unannounced annual inspection. Present during the inspection was the Licensee and her three (3) fingerprint cleared assistants. There were four (4) preschool children present during the inspection. Licensee lives in the home with her fingerprint cleared husband Oleksandr Mishyn. The Licensee’s home was toured for a health and safety inspection. The facility operates from 7:30am – 6:00pm.

ON LIMITS AREA: Living Room, Bedroom 1, Bathroom 1 and the Backyard


OFF LIMITS AREA: Bedroom 2, Master Bedroom and Bathroom, Bathroom 2, Laundry Room and Patio
ISOLATION AREA: Bedroom 1

The facility is a single-story home rented by the Licensee and her husband. The inside of the home is observed to be neat, clean with ample age appropriate materials for the children that are safe and clean. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas. Licensee has stated that there no firearms and two (2) cats.

The home has one (1) fully charged 2A10BC fire extinguisher in the closet by the front door. There is one (1) working smoke/carbon monoxide detector in the living room. The fireplace in the living room is covered and made inaccessible to the children. There is central heating in the home and it is equipped with many windows and fans for proper ventilation. There is a fenced in, fully drained, non-operational jacuzzi on the patio that is fully covered and supports the weight of the Licensee.


Cont on 809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: MISHYNA, HULIZAR
FACILITY NUMBER: 435700321
VISIT DATE: 08/27/2021
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At 11:09am LPA obtained the facility roster, staff files, and the children’s files. All files were complete. The Licensee’s Health and Safety training has been completed and CPR and First Aid training was completed and expires on 5/2023. Licensee’s Mandated Reporter training is complete and expires on 12/19/2021. All required forms are posted and visible for public view in the entry way of the home. Fire drill log is complete as well.

Licensee was reminded that California Law requires licensees to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed. This facility provides IMS to children in care. Facility is following IMS plan on file. When any changes to the IMS plan is made, an updated 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.

Licensee is reminded that ALL Licensees, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3,000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter.

All fire/disaster drill must be conducted every six months and documented. The Licensee is reminded that any structural changes to the facility or additions to the childcare facility must be reported to Community Care Licensing. Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates.

This report was read and given to the Licensee for a signature. Exit interview conducted. Notice of Site Visit was given and must be posted for 30 days
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
LIC809 (FAS) - (06/04)
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