274416254-6-18-2024-07-CC-ACOZ-D6D5VJ-20240618201737

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 274416254
Report Date: 06/18/2024
Date Signed: 06/18/2024 08:19:59 PM

Document Has Been Signed on 06/18/2024 08:19 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	MATROSOVA-KHALIL, SOFIA		FACILITY NUMBER:	274416254
ADMINISTRATOR/ DIRECTOR:	SOFIA MATROSOVA-KHALIL		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 277-4352
CITY:	SEASIDE	STATE: CA	ZIP CODE:	93955
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 3	DATE:	06/18/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:23 AM
MET WITH:	Sofia Matrosova-Khalil		TIME VISIT/ INSPECTION COMPLETED:	04:13 PM

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Licensing Program Analyst (LPA) Andrea Cortez conducted an unannounced Required - 1 Year Inspection (care tool). LPA was greeted and granted entrance by the Licensee Sofia Matrosova-Khalil. The purpose of today’s inspection is to ensure the childcare is in compliance with Title 22 California Code of Regulations. Todays census is 3: 1 infant 11 months and 28 days , 1 child 18 months, and 1 another child 2 1/2 years old. The Licensee her mother Valentina Matrosova, as well as adult daughters Leila and Nadia Khalil are the only adults who reside in the home. The day care hours of operation are Monday - Friday, 8am - 4:30pm. The Licensee's CPR and First Aid are current and expire 9/13/2024. The Licensee's fees are current.

LPA toured the indoor and outdoor areas of the ADU during today's visit. LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's visit. The last fire disaster drill was conducted on 01/30/2024. The Licensee has a working cell phone in the childcare. LPA observed sufficient materials, toys, and play equipment for the children in care. Licensee states the accessory dwelling unit (ADU) is approved by the city Seaside. Licensee has an update to the on and off limits of childcare. Entire home and backyard is off limits. Children's care is designated in the ADU. Licensee has sketched a new physical plant for file.

LPA observed a fully charged 2A10BC fire extinguisher however, fire inspection tag is missing, LPA issued Type B deficiency and proof of correction (POC) date for 7-09-2024. LPA observed working smoke, and carbon monoxide detectors. LPA did not observed a body of water present. The Licensee states that she does not have weapons in the home. All detergents, cleaning compounds, poisons, medications, and other similar items are out of reach and inaccessible to children. Licensee states that she does not administer medications at this time.

Supervision of children was discussed with the Licensee and she understands that she must be present in the ADU during day care hours to ensure that the children are safe and supervised at all times. The Licensee states that she does not transport children; however she understands that children cannot be left in parked vehicles unattended any time.

LPA observed staff immunization records on file.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MATROSOVA-KHALIL, SOFIA	FACILITY NUMBER: 274416254
	VISIT DATE: 06/18/2024

NARRATIVE

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LPA discussed the safe sleep regulations with the License 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 licensee 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 review of staff records on June 18 2024 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee Sofia Matrosova-Khalil was reminded that all adults 18 and over living or working in the home, 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.

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 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

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MATROSOVA-KHALIL, SOFIA	FACILITY NUMBER: 274416254
	VISIT DATE: 06/18/2024

NARRATIVE

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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.

No type A deficiencies cited. Exit interview conducted and report was reviewed with the Licensee Sofia Matrosova-Khalil.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 06/18/2024 08:20 PM - It Cannot Be Edited

Created By: Andrea Cortez On 06/18/2024 at 01:11 PM

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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MATROSOVA-KHALIL, SOFIA	FACILITY NUMBER: 274416254
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)

Admission Procedures and Parental and Authorized Representative's Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in C1, C2, and C3 files did not have copies of parent's rights LIC 995A. Which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2024
	Plan of Correction
1 2 3 4	Licensee to have parent's sign LIC 995A and keep in children's files. Once LIC995A is signed please email proof to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Gladys Kuizon

LICENSING EVALUATOR NAME:

Andrea Cortez

LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

Page: 4 of 7

Document Has Been Signed on 06/18/2024 08:20 PM - It Cannot Be Edited

Created By: Andrea Cortez On 06/18/2024 at 01:11 PM

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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MATROSOVA-KHALIL, SOFIA	FACILITY NUMBER: 274416254
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)(c)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Licensee has in care an 11 month old (C1) and 18 month old (C3) and no safe sleep log was in their files. Which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2024
	Plan of Correction
1 2 3 4	Licensee to complete and safe sleep log with name, date of birth, and dates. Once complete please email correction to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Gladys Kuizon

LICENSING EVALUATOR NAME:

Andrea Cortez

LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

Page: 5 of 7

Document Has Been Signed on 06/18/2024 08:20 PM - It Cannot Be Edited

Created By: Andrea Cortez On 06/18/2024 at 03:02 PM

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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MATROSOVA-KHALIL, SOFIA	FACILITY NUMBER: 274416254
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417

Fireplaces and open-face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on upon inspection, the licensee did not comply with the section cited above. Fire extinguisher is missing inspection tag signed by fire marshal. Which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/09/2024
	Plan of Correction
1 2 3 4	Licensee to make an appointment with Fire Marshal to have extinguisher inspected and signed off. Once completed please email LPA

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Gladys Kuizon

LICENSING EVALUATOR NAME:

Andrea Cortez

LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

Page: 6 of 7

Document Has Been Signed on 06/18/2024 08:20 PM - It Cannot Be Edited

Created By: Andrea Cortez On 06/18/2024 at 03:43 PM

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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MATROSOVA-KHALIL, SOFIA	FACILITY NUMBER: 274416254
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type B

Section Cited

HSC

40010

Laws regarding child abuse mandate that those professions identified as “Care Custodians” report any known or suspected instance of physical or sexual abuse of any child to a Child Protective Agency, including law enforcement. Employees of the Community Care Licensing Division (except clerical staff) are, for purposes of reporting child abuse, considered “Care Custodians” and must comply with specific reporting responsibilities when a complaint of abuse is received. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Mandated Reporter Certificate is expired. Which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2024
	Plan of Correction
1 2 3 4	Licensee to complete Mandated Reporter Training and email certificate to LPA by 7-18-24

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Gladys Kuizon

LICENSING EVALUATOR NAME:

Andrea Cortez

LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

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