Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405254
Report Date: 05/22/2018
Date Signed 05/22/2018 05:26:50 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: 12DATE:
05/22/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Natalia SiradzeTIME COMPLETED:
05:40 PM
NARRATIVE
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LPA, Fernando Colmenares met with Natalia Siradze to conduct a random annual inspection visit. Also present today was the provider's assistant S1 and 12 children in care. There were 4 infants and 8 pre-school age children. The children's records were reviewed and are in compliance. A copy of the roster was obtained from the provider. There are 5 working smoke alarm and a fully charged 3A-40B-C fire extinguisher. The home also has a Carbon Monoxide detector. The provider has renewed her Pediatric CPR Card which expires 12/20/18 and her Pediatric First Aid, which expires 12/20/18. The provider has a first aid kit. The facility file was reviewed. Fire drills are conducted and logged. No bodies of water were observed during this visit. The provider states there are no firearms in the home. A fact sheet on Assembly Bill 633 was given to the provider. This LPA, informed the provider of the web address, (www.ccld.ca.gov) for downloading child care forms to register to receive child care updates. Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. 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.
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Fernando ColmenaresTELEPHONE: (510) 292-7241
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2018
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
VISIT DATE: 05/22/2018
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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 The house was toured and found to be in compliance as originally licensed. The provider and her assistant have taken the Mandated Reporter Training.

A review of staff records today indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

SEE 809-D FOR DEFICIENCY.

Licensee was provided a copy of their appeal rights(LIC9058 12/15) and their signature on this form acknowledges receipt of these rights. A site visit notice was posted.

Exit interview with Natalia Siradze. This report must be kept available for public review for three years.

Failure to correct deficiencies will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Fernando ColmenaresTELEPHONE: (510) 292-7241
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2018
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: 05/22/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/25/2018
Section Cited
HSC
1597.662
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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. THE LICENSEE AND HERD ASSISTANT DO NOT HAVE PROOF OF THE ABOVE IMMUNIZATION'S.
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THE LICENSEE AND HER ASSISTANT WILL OBTAIN RECORDS FOR PERTUSSIS, MEASLES AND INFLUENZA IMMUNIZATION PER SB 792, AND MAIL THIS LPA A COPY BY 6/25/18. Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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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: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Fernando ColmenaresTELEPHONE: (510) 292-7241
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2018
LIC809 (FAS) - (06/04)
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