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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384000536
Report Date: 03/05/2020
Date Signed: 03/05/2020 03:26:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:NIKCHEMNY, VIKTORIYAFACILITY NUMBER:
384000536
ADMINISTRATOR:NIKCHEMNY, VIKTORIYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 665-7208
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY:14CENSUS: 11DATE:
03/05/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Viktoriya NikchemnyTIME COMPLETED:
03:30 PM
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On March 5, 2020, at 2:30 pm, Licensing Program Analyst (LPA) Van met with the licensee, Viktoriya Nikchemny, for an unannounced inspection of the Plan of Correction (POC). The purpose of the inspection was explained and was granted entry to the home by the licensee. Present, there are 11 children (3 infants and 8 preschoolers) in care with the licensee and 1 helper.

On February 4, 2020, annual inspection, the following deficiencies were cited. The licensee and helper did not have immunization records for review during the inspection and failed to keep a log or documentation of the fire & earthquake drill. Also, children's records review revealed multiple children were missing the Immunization records. In today's POC inspection, LPA observed that the licensee had conducted the fire and earthquake drill and adequately documented. Children and staff records review confirmed that all children and staff immunization were up to date. Deficiencies that were cited on January 22, 2020, are cleared today. Copy of Letter of Deficiency Citations Cleared will be sent to the licensee.

An exit interview was conducted with the licensee. A consultation was provided. No deficiencies are cited today. A copy of this report is reviewed and provided to the licensee. Notice of site visit is posted and shall remain posted for the next 30 days.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020
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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