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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313819
Report Date: 11/22/2021
Date Signed: 11/22/2021 04:06:56 PM

Document Has Been Signed on 11/22/2021 04:06 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:IVANCHUK, IVANFACILITY NUMBER:
304313819
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
11/22/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Licensee Mr. Ivanchuk, Ivan TIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Desai, Ketki conducted an unannounced In-person Case Management. Licensee initiated inspection for a change in capacity at the existing Family Child Care home. LPA met with Licensee 'Mr. Ivanchuk, Ivan along with three assistants (Ms. Sanij, Nahid , Ms. Ivanchuk, Inessa and Ms. Ahmadi, Hanyeh present at the site, providing care and supervision to children, assistant Ms. Sanij, Nahid gave a tour of the home. At the time of inspection there was 8 children in care.

A review of the Facility Personnel Report Summary indicates all adults, residing in the home who require caregiver background check clearances are cleared. There are only one adult residing in the home.

Licensee is requesting a Large family childcare home license. Per Licensee, operation hours will be Monday to Friday, 7.30 AM to 5:30PM, care and supervision shall be provided to children ages Preschool to school age children. (4 -12 years old)

A review of the Facility Personnel Report Summary dated (11/22/21) indicates all adults residents, who require caregiver background check clearances exemptions is received and are cleared. Licensee has three assistants who shall be assisting him in the operation of the Large family care home, the assistants have met the requirements.

Licensee stated he is not currently registered with any Foster Care agency or holds a foster parent license, He was informed if any changes are to occur, Department shall be notified.

Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation and heating. The home has a central Air /Heating system, the A/C unit is installed in the corner of the side yard inaccessible to children. (Page-1)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: IVANCHUK, IVAN
FACILITY NUMBER: 304313819
VISIT DATE: 11/22/2021
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There is a fireplace in the living are and it has been made inaccessible by a child safety barrier (A wooden bookshelf has been placed in front of it).
Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children. Per Licensee there are no poisons on the premises). Licensee was advised that any poisons must be locked with a key or combination lock.

Based on the Facility Sketch submitted, areas off limits to children and parents are: One Bedroom, one full bathroom (Next to the Guest room (Art room), garage on the first level, Three bedrooms, laundry room and three bathrooms on the second level of the home, Side yard is partially inaccessible, Licensee has made this areas inaccessible to children. There is chidl safety gate installed making the second level completely inaccessible to children and the Guest bedroom was observed to be locked. Side yard also has a fencing making the area inaccessible to children . Licensee understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

Designated Child care areas: Children shall enter the home through the main door of the home, right hand side is the designated day care area (Family room), dining room is across the kitchen. The designated half bathroom is next to the guest room (Art room) for the children. The designated Day care area (Family & Dining area) were observed to have age appropriate furniture and educational items for the children. The bathroom was observed to be safe and free of hazardous items. There is no cabinet under the sink. Kitchen is open, all the sharp objects are placed in the top cabinet inaccessible to children. No hazardous items were observed. Children have a relaxing time during their time at the FCCH, story telling and book reading is encouraged during this time. If the child wants to nap, Music room is utilized and it has a mat available for the child to relax.

Family/living area is open and spacious, the assigned guest room (Art room) is a room designated to additional activities. (Homework/ Arts and Crafts)

OUTDOOR PLAY AREA: The children shall use the community park area for outdoor walks, which is outside the home, as well as the enclosed patio area, which was observed to have age appropriate table top activities, there is small grass area, for additional activities and other side is partially accessible to children. There is a wall mounted barbecue was covered. No sharp objects were observed.

Per Licensee there are no, firearms, pets, weapons or bodies of water on the premises. (Page 2)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: IVANCHUK, IVAN
FACILITY NUMBER: 304313819
VISIT DATE: 11/22/2021
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The value on the 2A10BC fire extinguisher indicates fully charged, as indicated on service tag observed. Smoke and carbon monoxide detectors were tested and are operable.
Licensee states that Breakfast/ Lunch and snacks are provided to children in care. Food brought from the children’s homes, those containers shall be labeled with child’s name and properly stored or refrigerated. Licensee serves them home cooked meals and have enrolled in the Food Program.(Kid Craft program)

Licensee has completed the required Pediatric First Aid and CPR which expires 08/22. There are first aid supplies available. Due to language barrier, Licensee has requested an exemption for Mandated Reporter training. Written exemption has been requested for management approval.

Licensee has a cell phone which is used for childcare, and remains on the premises during hours of operation.



The following was discussed with the applicant: ·Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately.
Civil Penalties will be assessed if not in compliance.

·In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR certification and a valid criminal record clearance associated to the facility license along with TB test / Immunization and Mandated Reporter training.
·Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
Licensee was also made aware of the Child Advocacy program so he could receive the updated Quarterly reports and other information in a timely manner. [email protected]

Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.



Fire and safety drills must be performed every six months and documented for review by the Department.
(Page-3)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: IVANCHUK, IVAN
FACILITY NUMBER: 304313819
VISIT DATE: 11/22/2021
NARRATIVE
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Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
No smoking, no infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.

Incidental Medical Services (IMS): policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian ( Facility does have access to the program)



OTHER INFORMATION AND FORMS PROVIDED: (Posters were emailed to the Licensee)
Capacity Handout for a Large Family Child Care Home was provided.

Fire inspection from Orange County Fire Authority Fire inspection services have granted the fire clearance with specific instruction where the second level and garage is not permitted for Day care.

(Page:4)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: IVANCHUK, IVAN
FACILITY NUMBER: 304313819
VISIT DATE: 11/22/2021
NARRATIVE
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The licensee does have a current roster of children in care. Facility files and four children files were reviewed and meets the requirements. Fire drills are held quarterly and records are maintained.

The facility was complying for a (Large Family Child Care Home) with Title 22 Regulations at the time of inspection. A license will be issued after final review, in the event additional requirements are needed, the Licensee will be notified.

On today’s inspection each child was observed to have a safe, healthful and comfortable accommodation furnishing and equipment’s.

Exit interview held with the Licensee and the assistant present.

Appeal rights were presented and Notice of Site visit posted.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5