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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004964
Report Date: 10/19/2023
Date Signed: 10/19/2023 01:49:07 PM

Document Has Been Signed on 10/19/2023 01:49 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:SKOBA, SVITLANAFACILITY NUMBER:
414004964
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Svitlana SkobaTIME COMPLETED:
02:10 PM
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On October 19, 2023 @ approx. 10:15 AM, Licensing Program Analyst (LPA) Maria Olguin-Leon met with Licensee, Svitlana Skoba for an unannounced annual inspection. The purpose of the inspection was explained. Present today was Licensee, one helper and 5 children (4 infant and 1 preschool age). All adults working at facility have fingerprint clearance. LPA observed facility is operating over capacity limits. This is an immediate risk to children in care. A type A violation is issued this day for this deficiency. Hours of operation are Monday– Friday, 8:00 am - 5:30pm. Helper Caroline Daher helped with translation, as Licensee speaks Russian,

LPA and Licensee toured the home for health and safety hazards. Day Care Areas: Playroom, Dining room, Bedroom #2, Bedroom #3, bathroom #2 and backyard. Off Limits Areas: Kitchen, living room, master bedroom, master bathroom, and garage. Kitchen is barricaded with a childproof gate and living room is barricaded with a toy storage cubbies. Fireplaces is in off limits area and is properly barricaded. Home is well light and has proper ventilation. Cleaning supplies and other potentially harmful items are stored inaccessible to the children. All electrical outlets are secured with child proof covers. There are plenty of age-appropriate toys, books, child size furnishings, learning material, and sleeping mats. Playroom and dining room flooring is carpeting. Backyard has plenty of age-appropriate play toys, play structure, table, play kitchen and ride on toys all in good condition. Play structure is on cement patio and rubber floor mats are underneath to cushion falls. There is also grass area for children to play. Backyard is surrounded with a 5 ft. fence. There are no spas, pools, or other bodies of waters.

Home is equipped with a working dual carbon monoxide/smoke detector and a fully charged fire extinguisher. Isolation area for ill children will be in bedroom #3 and away from other children and supervised. First aid kit is fully stocked with supplies. Licensee uses a cell phone on the premises. Per licensee there are no weapons or firearms in the home. Parents provides sheets for sleeping mats and are washed weekly or when soiled. Licensee uses the HiMana app to document sleeping logs. Assistant was unable to retrieve logs from previous day, LPA discussed the importance of having logs available for LPA to confirm 15 minute sleep check, Licensee understood and will try to retrieve logs from app.

Cont. page 2…
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: SKOBA, SVITLANA
FACILITY NUMBER: 414004964
VISIT DATE: 10/19/2023
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LPA reviewed 6 children’s records and 1 staff record. LPA reminded Licensee to keep children’s record up to date and issued technical assistance. LPA reviewed children's roster. Licensee CPR/FA expires 10/2024. Licensee Mandated Reporter training expires 09/2024. Licensee provides Breakfast, Lunch, and afternoon snacks to children in care. LPA reminded Licensee to label children's food/bottles brought from home. LPA observed Childcare License, Emergency Disaster Plan (LIC610A) and Parent's rights, Licensee will move document next to entrance for easier accessibility to parents. Last emergency drill was conducted on 09/2023 and properly documented. Licensee carries Liability insurance with Accord and expires 09/2024.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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: https://www.ada.gov/resources/child-care-centers/.

The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. 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.

As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. LPA reminded licensee about Mandated Reporter training available www.mandatedreporterca.com

Cont. page 3...
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
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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: SKOBA, SVITLANA
FACILITY NUMBER: 414004964
VISIT DATE: 10/19/2023
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LPA discussed the safe sleep regulations with Licensee 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. LPAs also informed licensee [or facility representative] 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.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.



Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE, Svitlana Skoba confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS on 09/26/2023.

**See following page for deficiencies cited against the facility today under CCR, Title 22, Div. 12, Chapt. 1**

Type “A” violation was issued today. Licensee is advised to provide a copy of the Evaluation Report and all Type “A” Deficiencies cited, to the parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 shall be maintained in all Children's files.

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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
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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: SKOBA, SVITLANA
FACILITY NUMBER: 414004964
VISIT DATE: 10/19/2023
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A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee, Svitlana Skoba and Caroline Daher(translated report).
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
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Document Has Been Signed on 10/19/2023 01:49 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 10/19/2023 at 01:02 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: SKOBA, SVITLANA
FACILITY NUMBER: 414004964

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(a)
Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review], the licensee did not comply with the section cited above. LPA confirmed Licensee is operating overcapacity with 4 infants and 1 preschooler in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Licensee will terminate one infant by POC date to be in compliance and will submit new roster to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Marie Rodriguez
LICENSING EVALUATOR NAME:Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


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