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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004890
Report Date: 04/12/2022
Date Signed: 04/12/2022 01:34:37 PM


Document Has Been Signed on 04/12/2022 01:34 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:SOBIESKI, GRACE & ALEXANDERFACILITY NUMBER:
414004890
ADMINISTRATOR:SOBIESKI, GRACE & ALEXANDEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 566-8595
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY:14CENSUS: 0DATE:
04/12/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Alex and Grace SobieskiTIME COMPLETED:
01:45 PM
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On April 12, 2022 at 11:30 AM, Licensing Program Analyst (LPA) Cowan conducted an announced pre-licensing inspection for relocation. Present in the home this day applicants, 2 helpers and 2 minor children. Applicant lives in the home with spouse and three minor children. Applicant’s home is a 4 bedroom and 3 bathroom house. Day-care areas: lower level family room, kitchenette, lower level bathroom 3, lower level bedroom 3. Off Limit areas: Upper level kitchen, living room bedrooms 1, 2, and 3, and bathrooms 1 and 2 . The day-care operation hours are Monday to Friday from AM 8:15 to 5:15 PM.
Licensee applied for relocation on 03/30/2022. Licensee has a current license (#414004643) in Pacifica.

LPA toured and inspection the house and yard for health and safety hazard. There were a fully charged 2A10BC fire extinguisher, working telephone phone, and working smoke and carbon monoxide detectors in the home. Licensee already children’s furniture, some books, toys, and learning material into the house. There is no fireplace in the day care area. Per licensee, there was no guns, no weapons. Per licensee, she will provide breakfast and snack to the day-care children. LPA discussed with licensee about the IMS and provided a sample to her during the inspection. Licensee has 1 dog and five chickens. Chickens are housed in a coup beyond the fence of the play yard. LPA also discussed with the licensee about the Safe Sleep regulations during the inspection. Applicant’s CPR expires 2-5-25, and Mandated Reporter expires on 9-1-22.

LPA recommends licensure for licensee as of 4/13/22.

SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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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