<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073407669
Report Date: 02/13/2020
Date Signed: 02/13/2020 01:51:24 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:NIKITOVA, ANNAFACILITY NUMBER:
073407669
ADMINISTRATOR:NIKITOVA, ANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 533-8767
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:14CENSUS: 10DATE:
02/13/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Anna NikitovaTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 02/13/2020 at 1:15 PM Licensing Program Analysts (LPAs) Monica Mathur and Arminder Singh conducted an unannounced Plan of Correction (POC) Inspection at Anna Nikitova's family day care. Present during inspection were Licensee, 2 Assistant Helpers and 10 children (3 infants and 7 preschool age).

On 02/03/20 during an unannounced Annual Inspection, Licensee was cited for the following:
Type A: 102417 (g)(4): Operation of a Family Child Care Home
Type B: 102416.1 Personnel Records

During today's inspection, LPAs observed all cleaning supplies are stored in places inaccessible to children. Licensee submitted all required licensing forms and documents for her employees. Licensing report dated 02/03/20 was posted and LIC9224 was signed and kept in all child files.The citations are cleared and a Letters of Clearance were provided.

A NOTICE OF SITE VISIT WAS ISSUED, AND MUST BE POSTED NEAR THE FRONT ENTRANCE TO THE HOME FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 725-5998
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1