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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618101
Report Date: 09/21/2023
Date Signed: 09/21/2023 02:48:55 PM

Document Has Been Signed on 09/21/2023 02:48 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PROTSYUK, ANNAFACILITY NUMBER:
343618101
ADMINISTRATOR:PROTSYUK, ANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 761-4080
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
09/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Anna ProtsyukTIME COMPLETED:
03:10 PM
NARRATIVE
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On September 27, 2022 at 2:00 PM, Licensing Program Analyst (LPA) Michelle Perez met with licensee Anna Protsyuk for the purpose of an annual required one year inspection. There were no children currently in care. All individuals subject to criminal background review have obtained a criminal record clearance.

Monday through Friday 2pm to 8pm. Licensee will contact LPA when hours change.

A health and safety evaluation was conducted in all areas accessible to children. Off limits areas consist of: Master Bedroom/Bathroom.

LPA observed a fully charged 2-A-10-BC fire extinguisher, first aid kit, and functioning smoke and carbon monoxide detectors. Per licensee, there are no weapons or poisons in the home. Sharp knives are stored in a kitchen cabinet out of children’s reach. LPA observed a barricaded fireplace.

During file review, LPA observed all necessary Children’s documents. LPA observed a current children’s roster and fire drill log last updated July 2023. LPA observed First Aid/CPR certificate valid through January 2024.

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 followinginformation regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA available at: http://wwwada.gov/childqanda.htm

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PROTSYUK, ANNA
FACILITY NUMBER: 343618101
VISIT DATE: 09/21/2023
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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 [email protected]. 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.

Licensee was reminded that all adults 18 and over living or working in the honme, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPAs discussed the safe sleep regulations with licensee [or facility representative] and discussed the Child Care Licensing Safe Sleep webpage at http://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] 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.

A notice of site visit was given and must remain posted for 30 days. Exit interview was conducted and report was reviewed with the Licensee, Anna Protsyuk.

No deficiencies today

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
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