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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004696
Report Date: 10/27/2023
Date Signed: 10/27/2023 02:47:58 PM

Document Has Been Signed on 10/27/2023 02:47 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: 4DATE:
10/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Levina ViolettaTIME COMPLETED:
01:15 PM
NARRATIVE
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On October 27, 2023, Licensing Program Analyst (LPA) conducted an initial complaint investigation and met with Licensee Levina Violetta. Co-licensee Iana Nikolskaia also arrived during the visit. Children's and staff records were reviewed, and based on the staff records, it was found that Licensee's helper (H1) did not have the fingerprint clearance associated with the facility. Consequently, Type A and civil penalties were assessed.

See 809D for the Type "A" deficiency issued today. The Facility is advised to provide a copy of the Evaluation Report and the Type "A" Deficiency cited to the parents and guardians of children currently enrolled in care and parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 shall be maintained in all Children's files. This report will be maintained in the facility file and made available for public review three years after the thirty-day posting requirement has been met.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
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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Document Has Been Signed on 10/27/2023 02:47 PM - It Cannot Be Edited


Created By: Brendon Van On 10/27/2023 at 01:32 PM
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: LEVINA, VIOLETTA & NIKOLSKAIA, IANA
FACILITY NUMBER: 384004696

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2023
Section Cited
CCR
102370(d)(2)

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(a) Prior to the Department issuing a license, the applicant(s) and all adults residing in the home shall obtain a California criminal record clearance or exemption. (d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 102370(j) or
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Licensees must ensure that all individuals subject to a criminal record shall be cleared before working, residing, or volunteering in the facility. During the visit, Co-Licensee Iana Nikolskaia associated H1 with their facility. This deficiency is considered cleared today.
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This requirement is not met, as evidenced by: Based on record review and observation, an unassociated fingerprint helper was present while children were in care, posing an immediate health, and safety 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.
SUPERVISOR'S NAME:Garfield Leung
LICENSING EVALUATOR NAME:Brendon Van
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023


LIC809 (FAS) - (06/04)
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