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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001777
Report Date: 05/02/2024
Date Signed: 05/02/2024 02:23:20 PM

Document Has Been Signed on 05/02/2024 02:23 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PAVLOVA, INNA S.FACILITY NUMBER:
384001777
ADMINISTRATOR/
DIRECTOR:		PAVLOVA, INNA S.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 564-5549
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
05/02/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Inna PavlovaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On May 2, 2024., Licensing Program Analyst (LPA) Van conducted a required inspection and met the Licensee, Inna Pavlova. LPA explained the purpose of the inspection to the Licensee and was given access to the home. Upon entering the home, LPA noticed staff members were preparing and setting the table for lunch for the children. Three staff members, including the licensee, were supervising 10 preschool-age children. All adults present during the inspection have cleared criminal clearance verified with the CDSS Guardian site.

There are no changes to the childcare areas previously approved, with the same off-limits and childcare areas. The childcare areas are on the street level floor, including two playrooms, a nap room, a bathroom, a small deck on the side of the house, and a large outdoor deck on the back of the house. The off-limit areas are the staff bathroom next to the playroom, the kitchen, the small office, the living room on the second floor, the entire third level, the basement, and the garage. All off-limit areas are appropriately barricaded. The facility operation hours are Monday through Friday, 8:30 am – 5:30 am.

LPA conducted a thorough inspection of the childcare areas, ensuring there were no potential dangers or health and safety hazards. The childcare areas were found to be clean and in good condition, with age-appropriate toys for imaginative, creative, and manipulative play. The home is equipped with appropriate heating, lighting, and ventilation, and no potential hazards that could endanger children in care were observed. No fireplace was observed in the childcare areas. The facility had multiple fully charged fire extinguishers that met the minimum standard of 2A 10 BC, a carbon monoxide and smoke detector, and a functional phone for emergencies.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PAVLOVA, INNA S.
FACILITY NUMBER: 384001777
VISIT DATE: 05/02/2024
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The Licensee confirmed that no firearms or weapons were present on the premises. LPA did not observe baby walkers, bouncers, or similar equipment in the childcare areas, and the Licensee was reminded that smoking is prohibited in the family's childcare home.

The Licensee confirmed that no children currently enrolled in the facility require a crib or playpen. The licensee stated all the children enrolled are over two years old. LPA reminded the Licensee of the importance of safe sleeping for infants if or when she has infants in her care. Cribs or playpens must be kept clear of toys, blankets, or pillows, and any padding or mattress used must fit the dimensions of the crib or playpen. Additionally, a securely fitted bed sheet must be used. The facility must also ensure the safety of infants by conducting 15-minute napping checks for children up to 24 months old. The checks should be documented consistently with the check dates and available for review.

All helpers present have maintained complete records and have met all the necessary licensing requirements, including completing required immunizations, mandated reporter training, and maintaining a valid Pediatric CPR/First Aid certification.

All the required posting documentation, such as the facility license, Notification of Parental Rights, and Earthquake Preparedness Checklist, have been placed in a prominent area for parents or representatives to review. According to the licensee, regular fire and earthquake drills are conducted at least once every six months. The last drills were completed on 12/19/2023.

The records of all random children who were present were reviewed. The licensee maintains accurate records for each child, including vaccination records, parental rights forms, and complete emergency information. These emergency documents contain information such as the child's full name, phone number, and the location of a parent or authorized person who may be contacted in an emergency. The records also contain the name and phone number of the child's doctor and the parent's permission for the licensee to consent to emergency medical care if needed.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PAVLOVA, INNA S.
FACILITY NUMBER: 384001777
VISIT DATE: 05/02/2024
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The 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 licensee 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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) / (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: www.ada.gov/childqanda.htm.

Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a childcare 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.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PAVLOVA, INNA S.
FACILITY NUMBER: 384001777
VISIT DATE: 05/02/2024
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LPA reviewed AB 1207 with the Licensee. 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.

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

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.

During the exit interview, the LICENSEE, INNA PAVLOVA, confirmed that there are no Registered Sex Offenders living in the facility, and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

An exit interview was conducted, and the report was reviewed with the Licensee, Inna Pavlova.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC809 (FAS) - (06/04)
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