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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004696
Report Date: 05/03/2023
Date Signed: 05/03/2023 06:38:59 PM

Document Has Been Signed on 05/03/2023 06:38 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:LEVINA, VIOLETTA & NIKOLSKAIA, IANAFACILITY NUMBER:
384004696
ADMINISTRATOR:LEVINA, VIOLETTAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 409-9017
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
05/03/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Violetta Levina & Iana NikolskaiaTIME COMPLETED:
06:45 PM
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 On May 3, 2023, Licensing Program Analyst (LPA) Van conducted an announced prelicensing inspection and met with both applicants, Violetta Levina & Iana Nikolskaia. Both Applicants reside in this two-story single-family home, consisting of 3 bedrooms and three bathrooms. Childcare areas will be only provided on the first floor, which includes the playroom, the hallway by the entrance on the side of the house, the toilet & sink in bathroom #1, and the backyard. The off-limit areas are the bathtub & standing shower in bathroom #1, the piano room on the ground level, the entire 2nd floor, and the garage. All off-limit areas are made inaccessible to children. Days and hours of operation will be Monday - Friday, 8:00 am. to 6:00 pm, and care for children between birth to 5.9 years old. Per the Applicant, she plans to utilize the hallway as an isolation for sick/ill children.
LPA and the Applicants inspected the entire home for Health and Safety Hazards. The home is clean and orderly and has sufficient lighting and ventilation. There are a variety of age-appropriate toys and puzzles for the children. There are multiple imaginative play toys. All furniture and playthings were observed to be in good repair. The home has a smoke and carbon monoxide detector and a fully charged 2A10BC fire extinguisher. The smoke detector and carbon monoxide were tested and worked during the inspection. All harmful objects, sharp objects, and toxins are stored out of the reach of children and made inaccessible to children. The bathroom is clean. The Applicants state that no weapons, firearms, or pets are in the home. All Electrical outlets have plastic covers. The home has no body of water, such as a swimming pool, spa, hot tub, or fishpond. The backyard is clean, completely fenced, and has age-appropriate structures for children.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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: LEVINA, VIOLETTA & NIKOLSKAIA, IANA
FACILITY NUMBER: 384004696
VISIT DATE: 05/03/2023
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 LPA informed the Applicants that emergency drills are required every six months, and the Applicants must document the drills. The Applicants were reminded that baby walkers, exer-saucers, jumpers, bouncers, and other similar items should be inaccessible to children. In addition, booster chairs are only used for the purpose of feeding/eating. The Applicant was also reminded that smoking is prohibited at the daycare.
The Applicants plan to provide the children with snacks, breakfast, lunch, and dinner. The Applicants state they plan to purchase liability insurance for child care. LPA informed the Applicants that if child care insurance is not purchased, each parent must be given the Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282). Applicants' Pediatric FirstAid CPR and Mandated Reporter Training are valid, and copies have been submitted to the Department.
LPA reviewed with the Applicants the LIC 311D, Forms/Records to keep in the Family Child Care Homes, children's forms/records, facility forms/records, and all required postings such as License/Parent's Rights poster/Emergency Disaster Plan and Earthquake Preparedness checklist. In addition, the entrance Checklist was also provided to the Applicant. The Applicants plan to have all required posting in the hallway close to the children's cubbies.
License capacity and limitation were also reviewed with the Applicants. LPA informed the Applicants that if care is provided to the 13th and 14th child, who must be school-aged, parent notification and landlord consent are required.
LPA discussed the safe sleep regulations with the Applicants 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 Applicants 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.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
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: LEVINA, VIOLETTA & NIKOLSKAIA, IANA
FACILITY NUMBER: 384004696
VISIT DATE: 05/03/2023
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 The Applicants were informed 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.
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)/ (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
The Applicants were 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. The Applicant was encouraged to obtain a copy of regulations and current licensing forms through the Department's website at www.ccld.ca.gov. The Applicant was also reminded of Mandated Reporter Online Training for Child Care Providers (AB 1207) and the additional General Training, and both are available on www.mandatedreporteca.com.
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 platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
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: LEVINA, VIOLETTA & NIKOLSKAIA, IANA
FACILITY NUMBER: 384004696
VISIT DATE: 05/03/2023
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A license will be recommended upon receiving Fire Clearance approval.

The Applicants, Violetta Levina & Iana Nikolskaia, reviewed and signed the report. Today's report was provided to the Applicants. This report will be kept in the facility file and available for public review upon request. Desk duty is available Monday - Friday, 8:00 am – 5:00 pm. (650) 266-8800. Website for Forms and Regulations: www.cdss.ca.gov

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC809 (FAS) - (06/04)
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