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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314033
Report Date: 06/20/2023
Date Signed: 06/20/2023 12:52:32 PM

Document Has Been Signed on 06/20/2023 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:SLUCHENKOV, VLADISLAVFACILITY NUMBER:
304314033
ADMINISTRATOR:SLUCHENKOV, VLADISLAVFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 705-8163
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY: 12TOTAL ENROLLED CHILDREN: 11CENSUS: 11DATE:
06/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Naynara Tangeland, Asst.TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst(LPA) P Rivas conducted an unannounced case management visit as a result of information obtained during another visit.

LPA was advised by Ms. Tangeland that licensee was in Montana in training and had been gone for a month.
LPA spoke with licensee via telephone (cell number is on license). Licensee, Sluchenkov stated he had been in Montana for a month and he had notified CCL. LPA advised the only information LPA Rivas received was for his question about adding a person to license .Licensee stated he has returned to California on weekends beginning Fridays and returning Mondays for three weeks. Hours of operation for facility are Monday through Friday 8:30am to 5:00pm, facility is open year round. (technical violation for not having phone on premises, since assistant does have a cell phone)
Licensee also stated the adults that live here are fingerprinted and associated to this home. There are a total of 3 adults which includes himself and two room mates.
LPA reviewed Facility Personnel Report Summary for this date and did not find, Staff Elena Maslenkina and Room mate #1 Jinwon Kim under this license. Review of records indicate both individuals have fingerprint clearances but they have not been transferred to this facility as required per Title 22 Division 12 Chapter 1 under 102370(d) (2). Civil penalties will be issued.
Ms. Yulia Prisyazhnyuk arrived at 8:57 am to drop off fingerprint clearances for Elena Maslenkina and Jinwon KIm (clearances were under license #304313419) Ms. Prisyazhnyuk indicated she can help manage the home. Ms. Prisyazhnyuk left at 8:59am after LPA advised she was not associated to this facility . Review of documents provided by Ms. Prisyazhnyuk indicated the aforementioned individuals are fingerprint cleared but no documentation was provided showing a request for a transfer was completed.
LPA had also asked Ms. Tangeland to contact licensee for any transfer requests for clearances for Ms. Maslenkina and Ms. Kim but none could be found.
LPA interviewed Ms. Kim who stated she lived here today. Interview with Ms. Maslenkina stated she began working here on 04/17/23.

Cont on 809c page 2
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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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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: SLUCHENKOV, VLADISLAV
FACILITY NUMBER: 304314033
VISIT DATE: 06/20/2023
NARRATIVE
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During visit LPA requested copy of file for Ms. Tangeland who provided copy, Ms. Tangeland's 1st aid cpr certificate was not in file and Ms. Tangeland indicated the card was expired. However, LPA did find that Ms. Maslenkina had a current first aid cpr card that expires 05/14/24.

LPA Rivas informed assistant Naynara Tangeland that this report dated 06/20/2023 document(s) one Type A violation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Rivas informed Assistant Naynara Tangeland to provide a copy of this licensing report dated 06/20/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with Assistant Nynara Tangeland. 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.



Failure to comply with posting requirements shall result in an immediate civil penalty of $100. to provide a copy of this licensing report dated 06/20/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.


Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.. 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.

end of report

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/20/2023 12:52 PM - It Cannot Be Edited


Created By: Pat Rivas On 06/20/2023 at 11:27 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SLUCHENKOV, VLADISLAV
FACILITY NUMBER: 304314033

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
06/21/2023
Section Cited
CCR
102370(d)(2)

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Criminal Record Clearance(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
Request a transfer of a criminal record clearance as specified in Section 102370(j)
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assistant provided copy of fingerprint transfer requests during visit. Licensee will submit a certification that he understands the requirements and will conduct transfer, clearances prior to individuals being present in the facility. Written certification to be sent to LPA by plan of correction date. It can be
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This requirement was not met as evidenced by review of two records, Ms. Maslenkina(staff) did not have a transfer request in file, Ms. Jinwon Kim (room mate) did not a transfer request on file. This poses a health, safety and personal rights risk to children in care.
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emailed.

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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:Rina Lopez
LICENSING EVALUATOR NAME:Pat Rivas
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023


LIC809 (FAS) - (06/04)
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