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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414003076
Report Date: 09/28/2023
Date Signed: 09/28/2023 03:28:52 PM

Document Has Been Signed on 09/28/2023 03:28 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:MYZHALA, OKSANAFACILITY NUMBER:
414003076
ADMINISTRATOR:MYZHALA, OKSANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 255-2419
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
09/28/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Oksana MyzhalaTIME COMPLETED:
03:35 PM
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On 9/28/2023 at 2:35PM., Licensing Program Analyst (LPAs) Luis J. Gomez and Jonathan Tse, met with Licensee, Oksana Myzhala. Purpose of the inspection was explained and was for an unannounced; Plan of Correction inspection. Present was the licensee, licensee daughter/ helper, helper caring for 7 children (4 infants, 3 preschool age). LPAs inspected facility for health and safety hazards.

During today’s inspection, LPAs performed observations, record review and interviewed the licensee.

At 2:40PM, LPAs confirmed licensee is operating within the required capacity limit stated on license. The required Notice of ‘A-type Deficiency’ forms (LIC9224) have been signed by the authorized representatives and stored in children’s records. Per licensee, infant-age child, C1, will no longer return.

Required ‘Notice of Site Visit’ form has been posted on facility’s bulletin.

Deficiency issued on 9/19/2023, have been cleared and ‘Cleared Plan of Correction Letters’ were provided.

Based on today's inspection, no deficiencies were observed in the areas evaluated according to the Title 22 Division 12 Ca. Code of Regulations. Exit interview and report was discussed with Licensee, Oksana Myzhala, and signature of this form acknowledges receipt of these documents.

This report must be available in the facility for public review. Notice was provided and shall remain posted for 30 days. Licensee was advised for additional questions to call CCL Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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