Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405254
Report Date: 12/16/2015
Date Signed 12/16/2015 01:21:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SIRADZE, NATALIAFACILITY NUMBER:
073405254
ADMINISTRATOR:SIRADZE, NATALIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 640-1085
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:14CENSUS: 10DATE:
12/16/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Natalia SiradzeTIME COMPLETED:
01:45 PM
NARRATIVE
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LPA, Hollie, met with Licensee for the purpose of a RANDOM HEALTH AND SAFETY INPSECTION. Present are the Licensee's two staff, Ms. Vasilyeva and Ms. Portnova and a grandmother of one of the children (3 y/o) who may start in January, per the Licensee. Although this child is a part of the census, he is not part of the day care as he is here today only for a trial period, per the licensee.
The home remains as licensed in that there have been no structural changes to the home. The OFF LIMIT remain the master bedroom and garage. There is a working smoke detector and a charged 3a40 bc fire extinguisher and a carbon monoxide detector. There are no bodies of water or fire arms in the home, per the Licensee. There are no detergents, cleaning compounds, medications or other chemical items which could pose a danger to children during this visit. There is heating and ventilation for the safety and comfort of children. There is a working telephone in the home. The fireplace in the home is covered to prevent access. The home has a current roster which LPA viewed. The licensee will send a copy of the roster within one week to LPA. The licensee conducts and documents fire and disaster drills as required. The licensee states she is the only resident who resides in the home at this time. The licensee is aware that all person's 18 years of age or older, who frequently visit the home, work or reside in the home, shall be fingerprint cleared PRIOR to being in the presence of day care children. The licensee has current CPR/FA training. The Licensee was informed that if she has to leave the facility while children are in care, she must leave a fingerprint cleared adult who has current CPR/FA certificates in the care of day care children. All required forms are posted. Sampling of children and staff records were reviewed during this visit. Per the Licensee, there are no children present that take medication. Incidental Medical Service was discussed with the Licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future; she wishes to provide any IMS services to a child in care. The licensee was encouraged to log onto to our website at CCLD.CA.GOV for the details of what is required if the licensee cares for children who require Epi Pens, Inhalers and Glucose Monitoring.

LPA encouraged the Licensee to review our website at the above address to stay up to date and informed on Laws and Title 22 Regulations as it relates to her day care business.
SUPERVISOR'S NAME: Zakiya AliTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2015
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SIRADZE, NATALIA
FACILITY NUMBER: 073405254
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2016
Section Cited
102369b9
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102369(b)(9) Application for License. Licensees and any adult in the home, shall provide evidence of a current tuberculosis clearance, performed and signed by a physician not more than one year prior to or seven days after first day of employment.
NEITHER STAFF MEMBERS PRESENT TODAY HAVE TB TEST RESULTS AVAILABLE.
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THE LICENSEE WILL OBTAIN TB TEST RESULTS FOR BOTH STAFF PRESENT TODAY AND SUBMIT TO LPA BY JANUARY 20, 2016.
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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: Zakiya AliTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2015
LIC809 (FAS) - (06/04)
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