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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435700321
Report Date: 06/02/2022
Date Signed: 06/02/2022 12:01:02 PM

Document Has Been Signed on 06/02/2022 12:01 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:MISHYNA, HULIZARFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 937-4543
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 14DATE:
06/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Hulizar MishynaTIME COMPLETED:
12:00 PM
NARRATIVE
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On 06/02/2022 at approximately 7:30am, Licensing Program Analyst (LPA) Sabina Dodoo conducted an Unannounced Case Management- Other visit at the Family Day Care Home of Mishyna, Hulizar. The purpose of the visit was due to unusual incident reports that were reported to the Department. LPA met with Licensee Hulizar Mishyna and explained the nature of the visit. LPA toured the home inside and outside. The census was 14 children. All 14 children were toddlers. Two aides were also present who are both fingerprint cleared. (Tatsiana Hancharyk and Ia Gabadadze).

At 9:30am LPA observed 14 children entering the home but while walking to the home 4 children were taken by 3 women to a nearby park. LPA advised licensee that she is out of ratio. Licensee stated that the children were visiting and the women are the parents of the children. LPA explained in order to be in ratio all 4 children must be picked up by their parents.
At 10 am LPA reviewed 10 children's files and 3 staff files(Licensee included). CPR First aide and Mandated reporter Training are all current. Licensee and aides are following the immunization laws. All forms are posted for public view. LPA observed the bulletin board((parent’s rights, emergency disaster plan, earthquake drills and facility license). A copy of current Roster was obtained from Licensee by LPA.

There is one deficiency cited for today's visit. Based on LPA's observation Licensee is in violation of California Code of Regulations Title 22 Division 12 Chapter 1, Regulation Number 1012416.5(d)(1) (2) Staffing Ratio and Capacity. A Type A citation is documented on 809D. (Please see 809D page for further Details).

***Continued on 809C**
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Sabina Dodoo
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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: 06/02/2022
NARRATIVE
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The Licensee acknowledge, that for Type A Deficiency, the licensee shall post the LIC 809, 809C and 809D 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.

The LIC 9224 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 Director. A copy of the LIC 9224 was given to Licensee at time of this inspection.

An exit interview was conducted. Plan of correction discussed with Licensee. Appeal rights were given and explained to the Licensee Hulizar Mishyna. A Notice of Site Visit was given to Licensee. This report shall remain on file for 3 years.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Sabina Dodoo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/02/2022 12:01 PM - It Cannot Be Edited


Created By: Sabina Dodoo On 06/02/2022 at 11:31 AM
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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: MISHYNA, HULIZAR
FACILITY NUMBER: 435700321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2022
Section Cited
CCR
102416.5A(d)(1)(2)

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102416.5 Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided... when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either:

(1) Twelve children, no more than four of whom may be infants; or

(2) More than twelve and up to fourteen children only if the criteria in Section 1597.465 of the Health and Safety Code are met:
A large family day care home may provide care...12 children and up to and including 14 children, if all of the following conditions are met:

(a) At least one child is enrolled in and attending kindergarten or elementary school and a second child is at least six years of age.
(b) No more than three infants are cared for during any time when more than 12 children are being cared for.
This requirement was not met as evidenced by:
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Licensee will ensure all 4 toddlers who are not enrolled in the Family Child Care home will be picked up by the parents.
Licensee shall notify LPA when the facility is back in ratio. Licensee will send an email to LPA: Sabina.Dodoo@dss.ca.gov
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LPA observed 14 children entering the home of licensee. All 14 children were toddlers. The facility was out of ratio. This posses an immediate health, safety and personal rights risks to children in care.
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LPA will conduct an unannounced follow up visit to the facility to ensure Licensee is within ratio. The four children must not be present during Day Care hours.

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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:Chandra Charles
LICENSING EVALUATOR NAME:Sabina Dodoo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022


LIC809 (FAS) - (06/04)
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