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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414000933
Report Date: 02/04/2020
Date Signed: 02/04/2020 04:22:29 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:KOFMAN, NATASHAFACILITY NUMBER:
414000933
ADMINISTRATOR:KOFMAN, NATASHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 952-0656
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:14CENSUS: 10DATE:
02/04/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Kofman NatashaTIME COMPLETED:
04:25 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
Licensing Program Analyst (LPA) Saini conducted a POC (Plan of Corrections) inspection and met with licensee Kofman Natasha. Present in the facility licensee and her helper taking care of 10 Preschooler. Purpose of the inspection was to clear a deficiency cited on 01/08/20. On that day Licensee and her helper didn’t have the required immunization on the file.
LPA and licensee inspected the day care areas. Licensee has her immunization completed. Copy of the immunization is obtained during a visit however helper still required to show proof of immunity against Measles, Pertussis (whooping cough). Per licensee, Helpers immunization's will be submitted to the regional office by 02/25/20 positively. POC letter will be issued once helper’s immunization will be received.


***No deficiencies were cited today under CCR, Title 22, Division 12, Chapter 3***

Report was reviewed and provided to licensee. This report must be available in the facility for public review. Notice of site visit was observed being posted.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2020
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 1