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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004964
Report Date: 11/02/2023
Date Signed: 11/02/2023 01:12:08 PM

Document Has Been Signed on 11/02/2023 01:12 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: 4CENSUS: 3DATE:
11/02/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Svitlana SkobaTIME COMPLETED:
01:35 PM
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On November 02, 2023, at 12:10 PM, Licensing Program Analyst (LPA) Maria Olguin-Leon, conducted an unannounced, plan of correction (POC) visit. LPA met with Licensee, Svitlana Skoba, and explained the purpose of the visit. Present during visit was Licensee, and 3 children (2 infants and 1 preschool age). Licensee is within ratio of staff/children capacity.

On October 19, 2023, LPA Maria Olguin-Leon met with licensee for an annual inspection. During visit, LPA observed facility to be operating over capacity with 4 infants and 1 preschooler. LPA issued a Type A citation for operating over licensed capacity limits. A POC was developed with licensee.

As of this date, LPA Olguin-Leon confirmed the licensee to have two infants and two preschoolers enrolled. Helper is currently caring for two infant twins at children’s home per parent agreement. LPA took photo of correspondence for LPA regarding current accommodation of children. Infant twins will return at a later date, when capacity of daycare is increased, or infants turn 2 yrs. old. LPA observed licensee to be operating within licensed capacity limits on this date.

During today's visit, LPA observed signed and completed Acknowledgement of Receipt of Licensing Reports (LIC9224) for 5 children. One enrolled child was on vacation, Licensee will email signed LIC9224 to LPA. LPA observed facility site visit and reports posted.

Deficiency cited on October 19, 2023, has been cleared as of this date. LPA provided licensee copy of POC letter. No deficiencies were cited today.

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 licensee, Svitlana Skoba.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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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