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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435700377
Report Date: 07/26/2024
Date Signed: 07/26/2024 12:52:25 PM

Document Has Been Signed on 07/26/2024 12:52 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 EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:VOSKOBOINIK, MAKSIMFACILITY NUMBER:
435700377
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
07/26/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Maksim VoskoboinikTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 07/26/2024 at 10:00am Licensing Program Analyst (LPA) Christina Uribe, met with licensee Maksim Voskoboinik for an UNANNOUNCED ANNUAL INSPECTION. Present for the inspection were 5 daycare children and 1 fingerprint cleared assistant (Victoriia Demchenko). The licensee is within ratio today with 1 infant and 4 preschool-aged children. 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 currently operates Monday-Thursday 8:00am-6:00pm & Fridays 8:00am-5:00pm.

The facility is a single story home consisting of 4 bedrooms, 3 bathrooms, office, kitchen, living room, family room, dining area, laundry room, detached garage, and backyard which are neat and clean with heating and ventilation for safety and comfort. The off-limits areas will be made inaccessible by closed and/or locked doors and visual supervision.

On-Limit Areas: The two front bedrooms, two bathrooms, family room, living room, dining room, & backyard. Off-Limit Areas: The two back bedrooms, primary bathroom, laundry room, kitchen, office, & detached garage.

The facility’s outdoor play space is located in the backyard of the home. The play structure, equipment, and fence are all in safe condition free from hazards which could pose a risk to children in care. There is ample shade available and gates are closed at all times while children are in the yard. There are no pools, hot tubs or any other bodies of water present at the time of the inspection.

All hazardous materials and toxins are kept out of reach from children and are not accessible. The home has a fully charged 3A40BC fire extinguisher, working smoke detector, carbon monoxide detector, telephone and fully stocked first aid kit. Per licensee, there are no firearms on the premises or pets in the home.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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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Document Has Been Signed on 07/26/2024 12:52 PM - It Cannot Be Edited


Created By: Christina Uribe On 07/26/2024 at 11:48 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: VOSKOBOINIK, MAKSIM
FACILITY NUMBER: 435700377

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one child's file does not have the Consent for Emergency Medical Treatment (LIC 627) form and another child's Identification & Emergency (LIC 700) form needs a parent signature & date which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will ensure that all children's emergency forms are complete and in the file for review. Licensee will have these forms completed for these two children and email a scaned copy of these forms to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 08/02/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Christina Uribe
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: VOSKOBOINIK, MAKSIM
FACILITY NUMBER: 435700377
VISIT DATE: 07/26/2024
NARRATIVE
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The licensee completed the Health and Safety training, CPR/First Aid certification expires on 03/08/25 and has completed the mandated reporter training on 03/06/23. Licensee is reminded of their responsibility to renew CPR/First Aid and Mandated Reporter certificates every two years. The licensee conducts and documents fire and disaster drills twice a year and the last conducted drill was on 06/11/24. All required forms are posted and visible for public review.

Records: LPA Uribe reviewed 5 children’s files, personnel records, and Facility Roster. Individual Infant Safe Sleep Plans are complete and in child's file. Sleep Charts for sleeping infants were reviewed and within compliance of the Safe Sleep Regulations. The facility does not have liability insurance and Affidavit Regarding Liability Insurance forms (LIC 282) were reviewed.


CCLD Inspection Process: To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Criminal Record Clearance: 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.

Safe Sleep: 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.
Page 2 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: VOSKOBOINIK, MAKSIM
FACILITY NUMBER: 435700377
VISIT DATE: 07/26/2024
NARRATIVE
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Incidental Medical Services (IMS): Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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/resources/child-care-centers/.

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

Megan’s Law: During the exit interview, the licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Unusual Incident/Student Injury Report: Effective August 1, 2003 California Law requires Child Care 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 to the regional office by phone and the written report, LIC 624, within 7 business days.

One Deficiency and Three Advisory Notes issued today:

  • Type B Violation: One child's file does not have a Consent for Emergency Medical Treatment (LIC 627) form and another child's Identification & Emergency (LIC 700) form needs a parent signature.
  • Advisory Note (TV): Facility Roster (LIC 9040) form needs to be updated.
  • Advisory Note (TV): Some children's files have missing or incomplete immunization records.
  • Advisory Note (TV): A fastened bumper pad was observed in one crib.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal rights were given and reviewed. Exit interview conducted and report was reviewed with the licensee, Maksim Voskoboinik.

Page 3 of 3 ***End of Report***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC809 (FAS) - (06/04)
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