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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435700321
Report Date: 11/08/2024
Date Signed: 11/08/2024 04:43:18 PM

Document Has Been Signed on 11/08/2024 04:43 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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:MISHYNA, HULIZARFACILITY NUMBER:
435700321
ADMINISTRATOR/
DIRECTOR:
MISHYNA, HULIZARFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 937-4543
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
11/08/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Hulizar MishynaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 11/08/2024 at 1:45pm, Licensing Program Analyst (LPA) Jialing “Julianne” Zhu met with licensee Hulizar Mishyna for an unannounced annual inspection. Present during the inspection were licensee, two (2) fingerprint-cleared assistants, and 12 children (4 infants and 8 preschoolers) in care. The licensee is within ratio today. Upon arrival, LPA provided licensee a copy of the Entrance Checklist (LIC 126). The home was toured to conduct a Health and Safety Inspection. The facility’s current hours of operation are Monday - Friday from 8:00am - 6:00pm.

The on-limit areas are living room, two (2) bedrooms used by the living room for napping, bathroom by the patio, and a portion of the backyard.

The off-limit areas are primary bedroom and bathroom, kitchen, bathroom across from the nap rooms, patio, laundry room, and fenced off portions of the backyard, which will be inaccessible by closed and/or locked doors and visual supervision. Off-limit kitchen and portions of backyards are used as walkthrough to get from the inside space to the outdoor play area in the backyard.

The isolation area is bedrooms used for napping. When a child shows signs of illness, he/she will be separated from other children here.

The home is a single-story home rented by the licensee. The inside of the home is observed to be clean and orderly, with central heating and ventilation for safety and comfort. LPA observed there are ample safe and age-appropriate toys, play equipment and materials. All toxins, cleaning products, and hazardous materials have been made inaccessible to the children. There are two (2) cats in the home. Per licensee, there are no firearms in the home.

Page 1 of 4. See LIC 809C.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Jialing Zhu
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: MISHYNA, HULIZAR
FACILITY NUMBER: 435700321
VISIT DATE: 11/08/2024
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Licensee uses child-sized beds for napping, and each child have access to their own bed. Cribs/play yards are also in the facility with the correct size mattresses and fitted sheets. Licensee provides bedding to the children during nap time. Facility provides meals and snacks to children in care through a food program. Licensee does not provide transportation to children.

There is a fully charged 2A10BC fire extinguisher in closet next to the entrance. There is one (1) working combination smoke and carbon monoxide detector in the living room. On-limit bedrooms are also equipped with smoke detectors. The facility has phone service. There is a fireplace in the living room, which has been made inaccessible to children.

The outdoor play area is a portion of the backyard, which is fully fenced with visual supervision. The outdoor play area is free from defects or dangerous conditions. There is an ample supply of age-appropriate toys and activities available for children, and they are in good condition. There are no play structures that require anchoring. There is ample shade available, and gates are locked at all times while children are in the backyard. Off-limit portions of the backyard are made inaccessible by gates and fences.

There is a jacuzzi located in an off-limits area in the backyard, which is equipped with a tight lid that is locked and latched to prevent access to children in care. Child will temporarily have access to this off-limits area when walking through to go from the indoor day care space to the outdoor play area. 100% supervision is provided when children are walking through this area.

The licensee completed the Health and Safety training. The licensee’s Pediatric CPR/First Aid certification is current and expires on 02/03/2025. Licensee has completed the Mandated Reporter training for Child Care Providers and expires on 09/08/2025. All adults living in the home have obtained a criminal record clearance.

The licensee conducts and documents fire and disaster drills at least once every six months, and the last conducted drill was on 09/02/2024. All required documents are posted and visible for public review.

LPA reviewed six (6) children’s files and two (2) staff files. There is a current roster available for review. The licensee rents the property. The facility has liability insurance.

Page 2 of 4. See LIC 809C.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Jialing Zhu
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
Page: 8 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: MISHYNA, HULIZAR
FACILITY NUMBER: 435700321
VISIT DATE: 11/08/2024
NARRATIVE
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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 624B). Any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing. Incidents must be reported within 24 hours by phone, fax, or email. LPA informed the Licensee that all forms can be downloaded at www.ccld.ca.gov.

Licensee was also reminded that Mandated Reporter Training ("Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting https://mandatedreporterca.com/. Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years.

Licensee 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.

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.

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) or (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.

Page 3 of 4. See LIC 809C.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Jialing Zhu
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
Page: 9 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: MISHYNA, HULIZAR
FACILITY NUMBER: 435700321
VISIT DATE: 11/08/2024
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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.

No deficiencies cited during today's inspection. Six (6) Advisory Notes were issued.

Advisory Notes:

· Five (5) Technical Violations: 1 staff missing immunization records, 3 of 6 children’s files reviewed missing immunization records, 1 of 6 children’s files reviewed missing LIC 995A form, 2 of 2 infant (24 months and younger) files reviewed did not have 15 minute sleep check documentation, infants were sleep in nap rooms with the door closed.

· One (1) Technical Assistance: LIC 700 Identification and Emergency Information forms were incomplete and/or not signed by parents.

A Notice of Site Visit was given and must remain posted for 30 days. Exit interview was conducted, report was reviewed, and Appeal Rights were provided to licensee Hulizar Mishyna.

Page 4 of 4. End of Report.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Jialing Zhu
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
Page: 10 of 10