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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414000933
Report Date: 01/08/2020
Date Signed: 01/08/2020 11:45:53 AM

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:KOFMAN, NATASHAFACILITY NUMBER:
414000933
ADMINISTRATOR:KOFMAN, NATASHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 952-0656
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:14CENSUS: 9DATE:
01/08/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:TAMARA KLEVET AND KOFMAN NATASHATIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Saini met with helper Tamara Klevet for an Annual Random Inspection.Licensee Natasha Kofman (aka Popova) was not at house but arrived after 20 minutes. Purpose of the visit was explained to Licensee. Licensee owns home, and lives with adult Son in this 5 bedroom, 5 bathroom, three level house. Per Licensee, helper also lives in this house and over the weekends she goes back to Sacramento. A review of records indicates that all adults working and living in the home has criminal records clearance. The day-care operates 8:00am- 6:00pm Monday through Friday. Licensee has day-care insurance through USLI company.
Present in the facility was Licensee, and 1 helpers caring for 9 children. LPA inspected the day care area for health and safety purpose. Daycare areas are: Living room, Bathroom #1, Bedroom #1(napping only), Dining area, Kitchen, Hallway (walk through to backyard) and half of the backyard. Off limit areas are: entire upper level, entire lower level, and portion of backyard. All off limit areas are properly barricaded.
LPA observed the following:
Home is clean, orderly and equipped with age appropriate toys and equipment for children indoors and outdoors. Home has a working telephone, a working smoke, and fire extinguisher that meets the minimum requirements. There are no bodies of water or fireplace in the home. There are no poisons, detergents, cleaning products, or sharp objects accessible to day care children. Licensee states there are no guns or weapons in the home. Per Licensee Last fire drill was conducted on 12/01/2019. Licensee provides meals.
Children files were reviewed and are complete. All required postings are properly posted. Licensee has completed Mandated Reporter Training. Licensee's helpers primary language is Russian so she is exempted to take mandated reporter training for now.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020
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 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: KOFMAN, NATASHA
FACILITY NUMBER: 414000933
VISIT DATE: 01/08/2020
NARRATIVE
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Licensee was reminded that as of September 1, 2016, a person may not be employed or volunteer at a child care 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.

Licensee was informed about the Provider Information Notices (PINs) on CCLD website.


>Deficiencies were issued today under Title 22 Division 12 of the CA. Code of Regulations.

>This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. Notice of site visit was observed being posted.
Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020
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: KOFMAN, NATASHA
FACILITY NUMBER: 414000933
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2020
Section Cited

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Employee and Volunteer Immunization: H&S 1597.622 (a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles.
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This requirement is not met based on no records for review. Licensee and helper do not have the required immunizations. This is a potential health and safety risk.
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Per Licensee, she will obtain verification of immunization or immunity for herself and helper by 01/31/2020.
copy of the verifacton will be submitted to the department by the due date.


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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3