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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001202
Report Date: 04/14/2022
Date Signed: 04/14/2022 12:35:56 PM

Document Has Been Signed on 04/14/2022 12:35 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:PETROVA, TETJANAFACILITY NUMBER:
384001202
ADMINISTRATOR:PETROVA, TETJANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 242-5115
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Petrova TetjanaTIME COMPLETED:
12:30 PM
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On April 14, 2022, Licensing Program Analyst (LPA), Van, conducted an unannounced required annual inspection and met with Licensee Petrova Tetjana. The purpose of the inspection was explained and granted entry to the home by the Licensee. Present today are 7 children (4 infants and 3 preschoolers) with the Licensee and a helper. The facility complies with the license capacity and limitations today. All adults living or working in the home have a criminal background clearance on file. Daycare areas are on the street floor level, including the playroom, nap room, backyard, and the full bathroom and half bathroom. The off-limit areas the entire 2nd floor, and the garage. The Days and operation hours are 7:00 am – 6:00 pm, Monday – Friday. Per Licensee, when a child shows signs of illness, the Licensee will separate and have the child waiting in the nap room with a helper while contacting the parent to pick them up. The

LPA toured and inspected inside and outdoor play areas for health and safety hazards during the inspection. The daycare area is clean, orderly, and equipped with safe, age-appropriate toys, books, and play equipment. The home has adequate heating, lighting, and ventilation and is free from defects or conditions that endanger children in care. The home is equipped with a fully charged fire extinguisher, smoke and carbon monoxide detectors, and a working telephone. Fully stocked first aid supplies are available for children. All playpens are in good condition. LPA observed all four playpens had pillows and toys inside of them. LPA informed the Licensee of the safe sleep regulations. Immediately, the Licensee removed all mentioned items and stated she would not be placing these items in the playpens moving forward. Cots are provided to older children. All unused electrical outlets have a child-proof cover. Poisons, detergents, and cleaning compounds are stored in the garage.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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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: PETROVA, TETJANA
FACILITY NUMBER: 384001202
VISIT DATE: 04/14/2022
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The backyard play structures are age-appropriate, in good condition, and free of loose parts. There are no bodies of water in the facility. Per Licensee, there were no firearms or weapons in the home. The licensee stated she has two dogs. Both dogs are situated in the 2nd-floor off-limit area and had up-to-date vaccinations. LPA observed no baby walkers, bouncers, or any similar items in the daycare. Licensee understood that smoking is prohibited in family childcare homes.

The Licensee stated fire and Earthquake drill was last conducted on February 9, 2022. The Licensee provides breakfast, lunch, and PM snacks. During the inspection, LPA reviewed random records of children present. The Licensee has records for children in care, including immunization records and Parents' Rights forms. LPA observed each child has a complete emergency information card with the child's full name, telephone number, and location of a parent or authorized representative to be contacted in an emergency. However, two children's Consent for Medical Treatment forms were not signed by the parent. The Licensee stated the two children were new, and therefore the forms were not completed. Technical Violation was issued. The Licensee has valid childcare liability insurance in the file, valid until 6/4/2022. Pediatric CPR/First Aid of both Licensee and helper are valid. Licensee posted all the required forms, such as facility License, Notification of Parent's Rights, Earthquake Preparedness checklist, and Notification of Personal Rights.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with the Licensees and discussed the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the Licensee 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.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
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: PETROVA, TETJANA
FACILITY NUMBER: 384001202
VISIT DATE: 04/14/2022
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The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensees were informed 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. LPA reviewed AB 1207 with the Licensees. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

LPA encouraged the Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

The following documents were requested during the inspection that the Licensee needs to submit to Licensing and are readily available for future inspection. Submit by 4/22/2022.
1. LIC 508
2. LIC 9108
3. Ensure all Consent medical treatment forms LIC 627 are signed by parents.

The report was reviewed and signed by Licensee Petrova Tetjana. No deficiencies were observed in today's inspection. Today's report, 4/14/2022, and site visit notice will be sent to Petrova Tetjana email by the close of business on 4/14/2022. Confirmation of receipt is required, and a site visit notice must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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