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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004156
Report Date: 08/23/2021
Date Signed: 08/23/2021 03:58:06 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:POTASH, CHAYA M.FACILITY NUMBER:
384004156
ADMINISTRATOR:POTASH, CHAYA M.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 797-7231
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY:14CENSUS: DATE:
08/23/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Chaya PotashTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Tapia-Mandujano met with licensee, Chaya Potash to conduct a case management inspection per licensee’s request to add the dining room area as part of of the day care area for infant use only. Present in the home are licensee, licensee's assistant, licensee's husband, and 9 children.

Licensee rents a house with 3 bedrooms, 3 bathrooms, living/dining room, Great room, kitchen, and Roof deck. The great room is three steps lower from the main house. Hours of operation are Monday-Friday are from 8:45am-3:30pm DAYCARE AREA: Great Room, Living/dining room, Bathroom #1, roof deck (walk through the home to get to the roof deck) OFF LIMITS AREA: Bedrooms (3), Bathroom #2 & #3, and Kitchen.

LPA toured the day care area and observed that day-care area is clean, and home has proper lighting and ventilation. LPA inspected the living/dining room. The living/dining room was clean and spacious. LPA did not observe any harmful objects or substances. Licensee states that she will only use the dining/living room for infants only.

Based on observation, LPA will approve the dining/living room once picture of pack and play is received.

Copy of this report was emailed to the licensee. Signed copy of this report will be kept in the facility file and made available for public review. Desk Duty is available Monday through Friday between 8:00 AM - 5:00 PM at (650) 266-8800. Website for forms and Regulations: www.cdss.ca.gov
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Leslit Tapia-MandujanoTELEPHONE: (650) 350-2554
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021
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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