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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001777
Report Date: 01/19/2023
Date Signed: 01/19/2023 04:35:16 PM


Document Has Been Signed on 01/19/2023 04:35 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
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: 10DATE:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Inna PavlovaTIME COMPLETED:
04:30 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 January 19, 2023., Licensing Program Analyst (LPA) Van performed an annual 1-year mandatory inspection, which included checking the interior and exterior of the facility and discussing the required childcare paperwork with the Licensee. The purpose of the inspection was explained, and the Licensee granted LPA entry to the facility. The Licensee and two helpers supervised ten preschoolers. All adult living or working in the house has a criminal record clearance. Hours of operation currently are Monday-Friday from 8:300 am to 5:30 pm. Daycare areas are on the street level 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.

LPA and the Licensee toured the childcare areas for health and safety hazards. The childcare area is clean and organized, with age-appropriate toys and equipment. The house has sufficient lighting and ventilation. A functional telephone, multiple working smokes and carbon monoxide detectors, and a fully charged 2A10BC fire extinguisher are all in the house. The Licensee understood that no baby walkers, bouncers, exersaucers, or other similar items are permissible to be used during daycare hours. According to the Licensee, there are no bodies of water on the premises. Daycare children have no access to detergents, disinfectants, or cleaning chemicals. The Licensee stated there are no guns or weapons in the house. The Licensee and both helpers have valid CPR & First Aid certifications valid until 2024 and Mandated Reporter Training Certificate. Emergency drills are held quarterly, with the latest drills conducted on 12/9/2022, and each drill is appropriately logged/documented by the Licensee.
Continued on page 2...
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 01/19/2023
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
26
27
28
29
30
31
32
The children's roster has been reviewed and found to be complete and up to date. Children's files were reviewed. The Licensee maintains thorough records for all children in their care, including vaccination records and Parental Rights forms. LPA noted that each kid had a complete emergency card with the child's full name, phone number, and the location of a parent or authorized person who may be called in an emergency. There is no transportation provided. Capacity options were reviewed, and the Licensee acknowledges that care cannot be provided over the capacity specified on the license. The requirements for reporting suspected child abuse, as well as reporting requirements for unusual incidents, were discussed. All mandatory postings are posted (License/Parent's Rights poster/Emergency Disaster Plan and Earthquake Preparedness Checklist).

The Licensee 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 the 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.

LPA discussed the safe sleep regulations with the Licensees and discussed the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the 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 registering all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Continued on page 3...
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 01/19/2023
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
26
27
28
29
30
31
32
The 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: www.ada.gov/childqanda.htm.

The Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. LPA reviewed AB 1207 with the Licensee. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

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 inspectionprocess@dss.ca.gov. 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/process.

During today's inspection, no deficiencies were observed. Licensee Inna Pavlova read and signed the report. Today's report and site visit notice were provided to the Licensee. LPA informed the Licensee that a site visit notification must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3