435700321-9-1-2023-52-CC-MPRE-CVA2DV-20230901171858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435700321
Report Date: 09/01/2023
Date Signed: 09/01/2023 05:19:10 PM

Document Has Been Signed on 09/01/2023 05:19 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, HULIZAR		FACILITY NUMBER:	435700321
ADMINISTRATOR:	MISHYNA, HULIZAR		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 937-4543
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94306
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 13	CENSUS: 9	DATE:	09/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:01 PM
MET WITH:	Facility Staff - Yagana Aliyeva		TIME COMPLETED:	05:18 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 9/1/2023 at 2:01pm Licensing Program Analyst (LPA) Morgan Pringle met with Facility Staff Yagana Aliyeva for a Required – 1 Year Inspection. Present during the inspection was the Licensee’s two (2) helpers, Yagana Aliyeva, Tatsiana Hancharyk and nine (9) preschool age children. Licensee was not present at the home as she has just had a baby and is in the hospital. Licensee lives in the home with her husband Oleksander Mishyn. The facility operates 8:00am – 6:00pm, Monday – Friday. This facility primarily speaks Russian. ON LIMITS AREA: Living Room, Two (2) Bedrooms on the right side of the home (used for napping), Bathroom on the right side of the home, and Backyard OFF LIMITS AREA: Master Bedroom and Bathroom, 2^nd bathroom, Laundry Room, and Patio ISOLATION AREA: Bedrooms The facility is a single-story home rented by the Licensee. The inside of the home was observed to be neat, clean with ample age-appropriate materials for the children. All toxins, cleaning products, personal medications, and hazardous materials were observed to be in inaccessible areas. Facility Staff stated that Licensee provides all food for the children. All food that may be brought from the children’s home will be properly labeled and stored. All off limit areas are made inaccessible with locks, gates, and closed doors. Facility Staff stated Licensee does not transport children. Licensee uses child sized beds for napping. All bedding is clean and properly stored. All children sleep in their own beds and bedding is not shared. There are two (2) cats and no firearms in the home. There is 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 and a smoke detector in both bedrooms. The fireplace in the living room is covered making it inaccessible to the children in care. The home is equipped with central heat and has many windows for proper ventilation.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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 09/01/2023 05:19 PM - It Cannot Be Edited

Created By: Morgan Pringle On 09/01/2023 at 04:05 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: MISHYNA, HULIZAR	FACILITY NUMBER: 435700321
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2023
	Plan of Correction
1 2 3 4	Licensee's helpers will complete the Mandated Reporter training and submit to licensee. Licensee will send LPA Pringle a copy of the certificate of completion by end of day on the POC date.

Type B

Section Cited

CCR

102416(c)

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:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2023
	Plan of Correction
1 2 3 4	Licensee and her two helpers will obtain a EMSA approved Pediatric CPR & First Aid training certificate. If training cannot be completed by POC date Licensee and her helpers will register for a training that is held no later than 30 days from the POC date. Licensee will submit all 3 certificates of completion or proof of registration for the trainings.

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:

Jason Jang

LICENSING EVALUATOR NAME:

Morgan Pringle

LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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: 09/01/2023

NARRATIVE

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The backyard is fully fenced with ample age-appropriate materials for the children. There is a fully drained, covered, non-operational jacuzzi on the back patio. The cover is made to hold an adult as well. There is a shed that remains locked and inaccessible. The side of the back yard that wraps around to the right side of the home is gated and inaccessible to the children.

The facility is operating within its licensed capacity and is in ratio. Licensee’s Health and Safety training has been completed and EMSA approved Pediatric CPR & First Aid is expired. Licensee’s Mandated Reporter training is complete and expires 12/30/2023. All required forms are posted on the wall by the front door. LPA was unable to obtain the fire/disaster drill log due to Licensee’s absence. Facility staff was also unable to find the document. Licensee will send LPA a copy of the log once she returns home. All adults living and working in the home have obtained a criminal record clearance. LPA obtained the facility files, the helpers files, and a sample of the children’s files. Through record review it was found that both Licensee’s helpers were missing an EMSA approved Pediatric CPR & First Aid training and had not obtained a Mandated Reporter Certificate.

Deficiencies cited during LPA’s inspection:
· Both helpers present missing EMSA approved Pediatric CPR & First Aid training
· Both helpers present missing Mandated Reporter training certificates

Licensee was reminded that California law requires Licensees to report unusual incidents and/or injuries to children in care, to the child's parents, and to the Department within 24 hours by phone, fax, or email. Within seven (7) days from the incident, Licensee’s must submit the Unusual Incident/Injury form (LIC 624B) to the Department. Licensee was reminded that any structural changes or additions to the home must be reported to Community Care Licensing. Children’s Roster must be properly maintained, and fire/disaster drills must be conducted every six (6) months and documented. Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Licensee was also informed that Mandated Reporter Training ("Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting https://mandatedreporterca.com/. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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: 09/01/2023

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was reminded that all adults 18 and over living or working in the home, 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.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Facility Staff Yagana Aliyeva, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

LPA discussed the safe sleep regulations with Licensee 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 Licensee 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.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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: 09/01/2023

NARRATIVE

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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 platforms. To receive important licensed 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.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Facility Staff Yagana Aliyeva.

Language Links interpreter #16513 was used to review this report.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC809 (FAS) - (06/04)

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