414004761-2-11-2021-05-CC-AMEN-BY5VGA-20210211152512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004761
Report Date: 02/11/2021
Date Signed: 02/11/2021 03:25:16 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:	VOLKONSKA, VIKTORIIA		FACILITY NUMBER:	414004761
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	02/11/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Viktoriia Vokonska		TIME COMPLETED:	03:00 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	Due to COVID-19, field visits are suspended at this time. Licensing Program Analyst (LPA) Andrea Medlin met with applicant via tele-inspection for a prelicensing visit. Applicant and her two minor children reside in the home. Applicant advised that any person 18 years of age or older who lives in home, or provides any care and supervision to daycare children, shall have criminal record clearance on file. Applicant rents the home. The entire home is inspected for health and safety hazards. This is a one level home consisting of: 3 bedrooms, two bathrooms, kitchen, dining area, main room converted to a play room (living room), and a separated room called "library, and backyard area. The child care areas will be: main playroom (living room), library room, bedroom #1 for napping only, bathroom, and the gated off areas in backyard. The home has working smoke detectors, carbon monoxide (CO) detectors, and fully charged fire extinguishers. First aid supplies are available. Applicant will use a separated area for isolation of ill/sick children until picked up by parent/guardian. Per applicant, there are no firearms, weapons, or pets in the home. No pools, spas, hot tubs, fish ponds, or similar bodies of water are present in the home. Per applicant, she plans to purchase liability insurance for the child care upon receipt of her child care license. There are sufficient age appropriate toys, and children's equipment available. Bathroom is clean and hazardous materials are inaccessible to children. Applicant advised to conduct emergency disaster drills at least once every six months and log the date and time of the drill. If applicant provides care to the 7th and 8th child, who must be school aged, parent/guardian notification and landlord consent is required. The following is required to be posted in a prominent accessible location in view of parents: Emergency Disaster Plan (LIC 610), Parent's Rights (LIC 995A), and License (once received). (continued on next page 809-C)

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea Medlin	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

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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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: VOLKONSKA, VIKTORIIA	FACILITY NUMBER: 414004761
	VISIT DATE: 02/11/2021

NARRATIVE

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This home will meet the licensing requirements of a Small Family Child Care Home (FCCH) pending fingerprint transfer process completion through Guardian. Once Guardian has completed the background clearance transfer process for applicant/licensee, then licensure will be recommended and approved.

This report is reviewed with applicant and a copy of this report must be made available for public review upon request. This report is provided to applicant through email.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea Medlin	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

LIC809 (FAS) - (06/04)

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