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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336301310
Report Date: 04/18/2025
Date Signed: 04/18/2025 01:15:15 PM

Document Has Been Signed on 04/18/2025 01:15 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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:PAVLOV FAMILY CHILD CAREFACILITY NUMBER:
336301310
ADMINISTRATOR/
DIRECTOR:		PAVLOV,LAURAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(425) 387-2234
CITY:MENIFEESTATE: CAZIP CODE:
92586
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
04/18/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Applicant, Laura PavlovTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Brian Morris conducted an announced pre-licensing inspection for a large family childcare at the above home on 04/18/2025 at 10:00 AM. LPA met with Applicant Laura Pavlov, and applicants husband Anatoli Pavlov. who guided LPA on a tour of the home at 10:30 AM. There were 02 children present when LPA arrived. Applicant is applying for a large childcare license. Per Applicant, hours of operation will be Monday through Friday from 05:00 AM to 05:00 PM. Applicant states they will provide care for children Zero months to 13 years of age.

This is a two-story home consisting of 6 bedrooms, 5 bathrooms, a living room, kitchen, dining room, daycare room #1, daycare room #2, office, two laundry rooms, front yard and backyard. The home was inspected for safety, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children are kept in kitchen area above microwave inaccessible to children and cleaners are kept under the kitchen sink area which is a key locked cabinet.

Areas used by children include daycare room #1, daycare room #2, daycare laundry room, daycare restroom, daycare storage closet area/emergency supplies area, main house kitchen area, main house downstairs bathroom #1, main house downstairs family room. Areas off limits include Entire second floor (5 bedrooms and 3 bathrooms and closet areas), garage area, main floor office area, upstairs laundry room, off limit areas are made inaccessible by baby gates. Knives and other sharp utensils are locked in a kitchen cabinets above the microwave area. Cleaning products are made inaccessible by a baby lock.

The home is clean, neat, and orderly, there are Protective outlets throughout the home for protection. Smoke/carbon monoxide detector was observed, tested by applicant, and found to be operable.
NAME OF LICENSING PROGRAM MANAGER: Carlos Martinez
NAME OF LICENSING PROGRAM ANALYST: Brian Morris
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: PAVLOV FAMILY CHILD CARE
FACILITY NUMBER: 336301310
VISIT DATE: 04/18/2025
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Applicants have completed the required preventative health and safety course which includes nutrition and prevention of lead exposure, and the Pediatric First Aid and CPR. Applicants have required proof of immunizations on file. Proof of Mandated Reporter Training was also provided.

LPA observed age-appropriate toys and learning materials. The required (2A-10BC) fire extinguisher was observed in daycare room #1 and was purchased in 03/2025. LPA reminded applicant that the fire extinguisher must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors are working order and tested by Applicant.

Per Applicant, there are weapons or firearms in the facility. Applicant has two-gun safes, Ammunitions safe is in the garage area of the home, the Weapons safe is located in the main bedroom closet area, both areas are off limits.

According to the applicant, the children are not using an outdoor play space currently. The applicant will set up their backyard area for children once their pool is installed (Estimated completion date June 2025) and this has LPA completed the pool inspection for the facility. The outdoor play area was observed to be fenced. LPA noted that the yard contains construction materials currently as the applicant is having a in ground pool installed. Additionally, LPA observed the pool construction zone, which is currently not safe for children, the facility backyard area will be off limits until LPM and LPA complete pool inspection at a later date.

There are not any pools, spas, or other bodies of water. (If a pool is present, use the Body of Water Documentation handout to detail the fencing, gate, pool type, cover/alarm observations, and safety equipment. Document measurements in the CARE Tool Notes.)

The isolation area for a sick child waiting to be picked up will be in the daycare room #1, away from other children. LPA reviewed with applicant the LIC 311D, Forms/Records to Keep in Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.



APPLICANT OWNS OR RENTS/LEASES THE HOME:

The applicant, Laura Pavlov provided proof of control of property.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

NAME OF LICENSING PROGRAM MANAGER: Carlos Martinez
NAME OF LICENSING PROGRAM ANALYST: Brian Morris
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: PAVLOV FAMILY CHILD CARE
FACILITY NUMBER: 336301310
VISIT DATE: 04/18/2025
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LPA informed Applicant(s) of their reporting requirements. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. The Duty Officer is available to answer questions Monday – Friday 8:00am to 5:00pm at: 951-782-4200. In addition, a report can be emailed to UnusualIncidentReportsDO10@dss.ca.gov.

Fire and safety drills must be performed every six months and documented for review by the Department. Smoking is not allowed in a home that is licensed as a family day care home, and in those areas of the family day care home where children are present.



A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.

Annual fees must be paid promptly and by the due date or a late fee shall be assessed, and/or the License shall be terminated.

Changes should be reported to the Department as soon as they occur such as construction and remodeling, telephone number changes and/or if you move from the home.

Applicant states they will provide food for the children.

CHILDREN'S RECORDS REQUIREMENTS:


• LIC 700 Identification and Emergency Information
• LIC 627 Consent for Emergency Medical Treatment
• LIC 282 Affidavit Regarding Liability Insurance
• LIC 9150 Parent Notification Additional Children in Care
• LIC 9927 Individual Infant Sleeping Plan
• LIC 995A Notification of Parent’s Rights
• Immunization Record
NAME OF LICENSING PROGRAM MANAGER: Carlos Martinez
NAME OF LICENSING PROGRAM ANALYST: Brian Morris
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: PAVLOV FAMILY CHILD CARE
FACILITY NUMBER: 336301310
VISIT DATE: 04/18/2025
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FACILITY RECORDS:
• LIC 624B Unusual Incident/Injury Report
• LIC 9040 Child Care Facility Roster
• LIC 9052 Employee Rights,
• LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
• LIC 9149 Property Owner/Landlord Consent Form
• LIC 9151 Property Owner/Landlord Notification Form
• Proof of current pediatric CPR and First Aid Certificates
• Copy of your deed or lease/rental agreement
• Documentation of Fire and Disaster drills
• Proof of immunizations against pertussis (TDAP), measles (MMR), and influenza
• Mandated Reporter certificate – www.mandatedreporterca.com– must be renewed every two (2) years

FORMS TO BE POSTED
• LIC203 Facility License
• PUB394 Notification of Parents Rights Poster
• PUB 475 1-844-LET-US-NO
• LIC 610A Emergency Disaster Plan (Recommended)
• LIC 9148 Earthquake Preparedness Checklist (Recommended)

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

Applicant(s) was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.



LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources /safe-sleep as an additional resource. LPA also informed applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
NAME OF LICENSING PROGRAM MANAGER: Carlos Martinez
NAME OF LICENSING PROGRAM ANALYST: Brian Morris
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: PAVLOV FAMILY CHILD CARE
FACILITY NUMBER: 336301310
VISIT DATE: 04/18/2025
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On this date, 04/15/2025, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

There are no corrections required to meet licensure. The application for a Large Family Child Care Home will be submitted for approval with a maximum capacity of twelve (12) children, no more than four (4) of whom may be infants or up to fourteen (14) children when one child is at least six (6) years of age, and one (1) child is enrolled and attending kindergarten or elementary school.

An exit interview was conducted, and a copy of this report was reviewed with and handed to Applicant Laura Pavlov.

NAME OF LICENSING PROGRAM MANAGER: Carlos Martinez
NAME OF LICENSING PROGRAM ANALYST: Brian Morris
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC809 (FAS) - (06/04)
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