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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376101360
Report Date: 02/13/2023
Date Signed: 02/13/2023 10:29:51 AM

Document Has Been Signed on 02/13/2023 10:29 AM - 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:BLUM, DANIEL & KOPMAN, POLINA FCCFACILITY NUMBER:
376101360
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
02/13/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Daniel Blum and Polina KopmanTIME COMPLETED:
10:35 PM
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On 2/13/2023 at 8:45am, Licensing Program Analysts (LPAs), Selina Siao and Sherlynn Banas conducted a pre licensing inspection with both applicant Polina Kopman and husband/co-applicant Daniel Blum. The 4 bedroom, 3 bath two stories house was toured and inspected to ensure an environment safe for the care and supervision of children. The home has a fully charged fire extinguisher size 2A10BC, smoke and carbon detector that meet requirements and are operational. All hazardous items were latched/locked and secured out of reach of children. The home has a spa located in the backyard that is covered and locked and the cover can support the weight of an adult. Applicant stated that the home doesn't have any weapon. Both applicants has an EMSA approved pediatric CPR and First Aid card that are current due to expire on Dec 3, 2024. Both applicant completed the 8 hours preventative health practice training on Nov 27, 2022. A review of the application and records on this date indicates that both applicants are the current adult residents at the home with the require TB clearances, caregiver background checks and child abuse clearances and has the required immunization. Applicants owns the property and has provided proof of ownership to the department.

Applicants will be using the following areas for childcare: living room (kids area), bedroom downstairs (napping), bathroom and fenced backyard for outdoor activity area. Off limits area: all of upstairs, kitchen, family room, laundry room and garage. The home has a fireplace that is in an off limit area. Off limit areas are blocked off with safety gates and there is a gate at the bottom of the stair.

Applicants was reminded of requirements for children’s records, facility roster, child abuse and unusual incident reporting, immunizations, car seat law and SIDS. Applicant was reminded that corporal punishment, smoking, baby walkers, exersaucers, bouncy seats and baby jumpers are not allowed in day care. The ABC’S of Safe Sleep: Sleep is Safest: Alone, on their Back in an empty Crib on a firm mattress. LPA reviewed with both applicants the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2023
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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: BLUM, DANIEL & KOPMAN, POLINA FCC
FACILITY NUMBER: 376101360
VISIT DATE: 02/13/2023
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Applicants shall comply with all regulations and laws governing family childcare homes and be financially secure to operate a family childcare home for children.

Both applicants 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, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with both applicants 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 both applicants 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)/ (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

All unusual incident reports shall be submitted to Licensing office via email at [email protected] or via fax at (619)767-2203.

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 platform.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: BLUM, DANIEL & KOPMAN, POLINA FCC
FACILITY NUMBER: 376101360
VISIT DATE: 02/13/2023
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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.


The following correction is needed prior to granting a license within 7 days:
  • Applicant Polina Kopman and co-applicant Daniel Blum needs to completed the online mandated child abuse training.
  • Submit a facility sketch for the upstair area.

Exit interview conducted and report was reviewed with both applicants.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
LIC809 (FAS) - (06/04)
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