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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001777
Report Date: 05/21/2026
Date Signed: 05/21/2026 05:40:03 PM

Document Has Been Signed on 05/21/2026 05:40 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 CC RO, 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: 13CENSUS: 11DATE:
05/21/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:05 PM
MET WITH:Inna PavlovaTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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On May 21, 2026, Licensing Program Analyst (LPA) Van conducted an announced annual inspection and met with Licensee Inna Pavlova, who granted LPA access to the home. Upon entry, LPA observed the licensee and two assistants supervising 11 preschool-aged children. The licensee was operating within her licensed capacity and limitations.

LPA verified that all adults residing or working in the home have criminal record clearances through the CDSS Background Check System. The licensee confirmed that no changes have been made to the previously approved childcare areas.

LPA began the inspection with a walkthrough of the approved childcare areas, which include two playrooms, a nap room, a bathroom, a small side deck, and a large rear deck. The off-limit areas consist of the staff bathroom, kitchen, small office, second-floor living room, entire third level, basement, and garage; all were properly barricaded. The facility operates Monday through Friday, 8:30 a.m. to 5:30 p.m.

The childcare areas were clean, organized, and equipped with appropriate materials that support learning and exploration. Heating, lighting, and ventilation were adequate. A functioning carbon monoxide detector, smoke alarm, and a fully charged 2A:10BC fire extinguisher were present. Cleaning supplies and disinfectants were stored out of children’s reach. The licensee stated that no firearms or weapons were in the home. No baby walkers, bouncers, or similar prohibited equipment were observed. LPA reminded the licensee that smoking is prohibited in the family child care home.


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NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Brendon Van
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2026
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PAVLOVA, INNA S.
FACILITY NUMBER: 384001777
VISIT DATE: 05/21/2026
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The small side deck is a compact, enclosed outdoor space directly off the childcare area, fully gated with secure railings, a level surface, and age-appropriate toys for brief outdoor activities. The large rear deck serves as the primary outdoor play space and is spacious, fully fenced, and arranged to allow safe movement and clear supervision. Age-appropriate outdoor toys and lightweight play structures were present, and the deck flooring was in good repair with no loose boards, splinters, or protruding nails. Both decks were clean, well-maintained, free of hazards, and appropriate for preschool-aged children.

The licensee stated that her program provides care only to preschool-aged children older than 2 years and does not currently enroll infants. However, the licensee understood the infant safe sleep regulations, including the requirement that cribs and playpens be free of loose items, that mattresses and sheets fit properly, that 15-minute sleep checks be documented for children up to 24 months, and that sleep sacks are prohibited.

LPA reviewed children’s records, which included complete emergency information, immunization records, and required parental rights forms. Personnel files for the licensee and assistants contained required immunizations, valid Pediatric First Aid/CPR certifications, and current mandated reporter training certificates.

All required postings were observed. The licensee reported that fire and earthquake drills are conducted at least every six months, with the most recent drill completed on 5/5/2026.

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.

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.


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NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Brendon Van
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PAVLOVA, INNA S.
FACILITY NUMBER: 384001777
VISIT DATE: 05/21/2026
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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.

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.

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.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare 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.

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Brendon Van
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC809 (FAS) - (06/04)
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