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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004964
Report Date: 12/07/2022
Date Signed: 12/07/2022 11:04:54 AM

Document Has Been Signed on 12/07/2022 11:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SKOBA, SVITLANAFACILITY NUMBER:
414004964
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
12/07/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Svitlana SkobaTIME COMPLETED:
11:37 AM
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On December 7, 2022., Licensing Program Analyst (LPA), Sheran Lo met with applicant, Svitlana Skoba for a schedule prelicensing inspection at the facility. Present is the applicant. Applicant rents the home, which is a three bedroom, two bathroom, single family home. Living in the home is applicant. Criminal record clearances are on file. Days and hours of operation are Monday - Friday, 8:00 AM. to 5:30 PM. Daycare Area: Living Room (Playroom), Dining Room (Study Room), Bedrooms #2 & 3, Bathroom #2, and Backyard. Off-limit Area: Bedroom #1 and Bathroom #1. LPA inspected home with applicant for health and safety hazards.

At 10:00 AM, The following was observed: Childcare area was clean and orderly with a variety of age appropriate toys, books and sitting areas with tables and chairs for the children. Furniture and playthings inspected are new and in good condition. Napping room, located next to the playroom, had mats. Baskets and hangers had been added to the facility closet for storage of children’s belongings. Playroom had one child size table and several chairs and activities. Study room had 2 tables and 8 chairs for meal times and other uses. Per applicant, meals will be provided. Gates has been installed to barricade off- limit areas. Bathroom #1 was in operating condition with adequate supplies. Playroom and Study room has windows for ventilation and lighting which the opening is inaccessible to children. LPA observed all accessible electrical outlets, trash bins had been properly covered. Detergents and cleaning supplies were made inaccessible, stored under the off-limit bathroom sink. Facility has functioning cell phone, smoke/ carbon monoxide detector combo and fire extinguishers (2A:10:BC). Per applicant, she has no pets. Per applicant, there are no guns or weapons in the home. Playroom was free of hazards or dangerous conditions. Isolation area for an ill child will be Bedroom #2 or #3. Applicant was informed that the Department must be notified that prior to use of any off-limits areas. Licensing forms and posting requirements were reviewed with the applicant.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Sheran Lo
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SKOBA, SVITLANA
FACILITY NUMBER: 414004964
VISIT DATE: 12/07/2022
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Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant 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.

This facility plans to provide Incidental Medical Services – IMS. For IMS information , see PIN 22-02-CCP. 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

Exit interview conducted and report was reviewed with the applicant.

LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted

Entrance Checklist was provided to the applicant.

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.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Sheran Lo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
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