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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001758
Report Date: 03/26/2025
Date Signed: 03/26/2025 11:14:53 AM

Document Has Been Signed on 03/26/2025 11:14 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HARRIS, MARLISFACILITY NUMBER:
384001758
ADMINISTRATOR/
DIRECTOR:		HARRIS, MARLISFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 751-7977
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 12DATE:
03/26/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:32 AM
MET WITH:Karina Vasilevska-Das and Anna SklarzTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
NARRATIVE
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On March 26, 2025, Licensing Program Analyst (LPA) Hanson Leong conducted an unannounced plan of correction (POC) visit to follow up with a Type A deficiency cited on March 19, 2025. LPA met with the Licensee’s two assistants, Karina Vasilevska-Das (S1) and Anna Sklarz (S2), and explained the purpose of the visit. The licensee was not present for today’s visit. According to S1 and S2, the licensee is still on vacation and will return to the facility on April 12, 2025.

Today’s visit included twelve pre-k children, S1, and S2.

On March 19, 2025, the facility was issued a Type A deficiency for not having staff on-site with current Pediatric First Aid and CPR certification. As a result of receiving a Type A deficiency, the facility must post the notice of site visit and the LIC 809D (the deficiency page) from March 19, 2025. Additionally, the facility must notify parents or guardians of the enrolled children of the Type A violation that was received via form LIC 9224, Acknowledgment of Receipt of Licensing Reports

LPA observed that S1’s Pediatric First Aid and CPR certification was completed on March 24, 2025, and is set to expire on March 24, 2027.

LPA observed that S2’s Pediatric First Aid and CPR certification was completed on January 26, 2024, and is set to expire on January 26, 2026.

LPA observed that the notice of site visit from March 19, 2025, was posted on the front door.

LPA observed that the facility did not post the LIC 809D (the deficiency page) from March 19, 2025.

See Page 2

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Hanson Leong
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2025
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 5
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HARRIS, MARLIS
FACILITY NUMBER: 384001758
VISIT DATE: 03/26/2025
NARRATIVE
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Page 2
Based on the interviews with S1 and S2, the facility did not provide form LIC 9224 to the parents or guardians of the enrolled children. According to S1 and S2, the parents were verbally notified of the Type A deficiency.

Based on the interviews with S1 and S2, the licensee’s temporary absences exceeded 20 percent of the hours that the facility provides care per day.

The facility was issued a $100 immediate civil penalty for failing to comply with posting requirements for 30 consecutive days.

Please refer to LIC 809D for today’s deficiencies.

Appeal Rights were given to the facility representative, Anna Sklarz.

A Notice of Site Visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Anna Sklarz.

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Hanson Leong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/26/2025 11:14 AM - It Cannot Be Edited


Created By: Hanson Leong On 03/26/2025 at 09:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HARRIS, MARLIS
FACILITY NUMBER: 384001758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2025
Section Cited
HSC
1596.8595(a)(1)

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HSC 1596.8595 Posting licensing report…
1596.8595(a)(1) Each licensed child day care facility shall post a copy of any licensing...
This requirement has not been met as evidenced by:
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S2 posted the LIC 809D page from March 19, 2025, on the front door. As of today, the deficiency will be cleared.
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Based on observation and interview, the licensee did not comply with the section cited above. LIC 809-D, issued on March 19, 2025, was not posted in the facility, which poses/posed a potential health, safety, or personal rights risk to children in care.
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Type B
04/26/2025
Section Cited
HSC1596.8595(c)(1)

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HSC 1596.8595 Posting licensing report…
c)(1) A licensed child day care facility shall provide to the parents or guardians...

This requirement has not been met as evidenced by:
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The licensee must have form LIC 9224 completed and submitted to the department by the due date of April 26, 2025
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Based on observation and interview, the licensee did not comply with the section cited above. Form LIC 9224 were not given to the enrolled children, which poses a potential health and safety risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Garfield Leung
NAME OF LICENSING PROGRAM MANAGER:
Hanson Leong
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/26/2025 11:14 AM - It Cannot Be Edited


Created By: Hanson Leong On 03/26/2025 at 10:03 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HARRIS, MARLIS
FACILITY NUMBER: 384001758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2025
Section Cited
CCR
102417(a)

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102417 Operation of a Family Child Care Home
(a)The licensee shall be present in the home and shall ensure that children in care are...
This requirement has not been met as evidenced by:
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The licensee will be required to provide a written statement outlining measures to prevent future occurrences.

The plan of correction is due on April 26, 2025.
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Based on observation and interviews, the licensee did not comply with the section cited above. The licensee is currently on vacation, which poses/posed a potential health, safety, or personal rights risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Garfield Leung
NAME OF LICENSING PROGRAM MANAGER:
Hanson Leong
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2025


LIC809 (FAS) - (06/04)
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