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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001777
Report Date: 12/17/2019
Date Signed: 12/17/2019 01:06:24 PM

COMPREHENSIVE INSPECTION
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:PAVLOVA, INNA S.FACILITY NUMBER:
384001777
ADMINISTRATOR:PAVLOVA, INNA S.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 564-5549
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY:14CENSUS: 11DATE:
12/17/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Inna PavlovaTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA), Van conducted an unannounced annual inspection and met with Licensee, Inna Pavlova. The purpose of the inspection explained and granted entry to the home by the licensee. Present in the facility are 12 children with the licensee (11 preschool and 1 infant) and 2 helpers. This facility is a three stories single-family house. Licensee owns this house. Daycare areas are on the ground floor including two playrooms, a nap room, two bathrooms, a small deck on the side of the house and a large outdoor deck on the back of the house. Per Licensee, sick children will be separated from the group and and will be waited in the living for parents to pick up.

LPA and licensee inspected the daycare areas for health and safety hazards. LPA observed the following: The daycare area is clean, orderly, and equipped with age-appropriate toys and equipment for the children. The home has adequate lighting and ventilation. Home has a working telephone, working smoke and carbon monoxide detector, and a fully charged fire extinguisher. First aid supplies are available for children. Per licensee, there are no firearms, weapons, or pets in the home. LPA observed no pools, spas, or other bodies of water on the premises. All poisons, detergents, or cleaning products are stored inaccessible to daycare children. LPA observed licensee had posted all the required forms (i.e., License, Notification of Parent's Rights, Notification of Personal Rights, and Emergency Disaster Plan). Fire drills are conducted and documented accordingly, and the last fire drill was conducted on 11/8/19. The licensee has complete records for children in care, including immunization records and Parents' Rights forms. Licensee Pediatric FirstAid & CPR will expire on 1/20/2020.

During the inspection, the following was discussed with the licensee.
*Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website.
*Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com)
*Licensee was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Licensee was given information regarding 'Safe Sleep' practices.
*LPA discussed the Family Child Care Home checklist and provided the checklist to the licensee as a reference for future inspection guide.

No deficiencies were observed today. A copy of this report was reviewed and provided to the licensee. This report will be kept in the facility file and will be made available for public review upon request. Notice of Site Visit was observed to be posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019
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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