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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004964
Report Date: 01/16/2025
Date Signed: 04/17/2025 05:38:41 PM

Document Has Been Signed on 04/17/2025 05:38 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/
DIRECTOR:		SKOBA, SVITLANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 445-1385
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 7DATE:
01/16/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Caroline DaherTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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***** THIS IS AN AMENDED REPORT FROM ORIGINAL DATED 01/16/2025 *****

On January 16, 2025, at approximately 11:45 am, Licensing Program Analyst (LPA) Maria Olguin-Leon conducted an unannounced annual inspection and met with helper (H1) Caroline Daher, and purpose of inspection was explained. Per H1, licensee was at an appointment. Present during today’s visit were two helpers and 7 children (3 infants and 4 preschoolers). Facility is operating within capacity and ratio requirements on this day. Childcare hours of operation are Monday - Friday from 8:00 am to 5:30 pm. Licensee returned from appointment at approx. 2:45 pm.

LPA and helper toured the indoors and outdoors of the home for health and safety hazards. Home is a single-story home. Day Care Areas: main daycare room, dining room, bedroom #2 (napping room), bedroom #3, bathroom and backyard. Off Limits Areas: living room, bedroom #1(master bedroom), master bathroom, kitchen, and garage. Per H1, bedroom #3 is currently not being used for daycare, as H1 will be moving into bedroom. Isolation Area: Sick children will be isolated in dining room and away from other children. LPA observed home to be clean and orderly with proper lighting and ventilation. Childproof gates are located at entrance to kitchen for inaccessibility to children. Main daycare room and living room are barricaded with a toy storage cubby. There is a fireplace in the off-limits living room. Bathroom was observed to have children’s toiletries. All cleaning supplies or potentially harmful items are stored behind locked cabinet and inaccessible to children in care. LPA observed electrical outlets are secured with child proof covers and inaccessible to children with furniture. There are plenty of age-appropriate toys, child size furnishings, learning material and sleeping mats. Backyard flooring is a cement patio and surrounded with grass. Backyard is equipped with swing/slide play structure, ride on toys, picnic table and other age-appropriate toys. Play structure is on cement patio and has rubber mats underneath to cushion falls. LPA did not observe any spas, pools, or other bodies of water. Entire backyard is surrounded by a 5 ft wood fence. LPA observed plants in backyard to be barricaded. LPA and H1 discussed extending barricade to cover aloe vera plants in backyard.

Cont. page 2…
NAME OF LICENSING PROGRAM MANAGER: Carol Marcroft
NAME OF LICENSING PROGRAM ANALYST: Cindy Interiano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SKOBA, SVITLANA
FACILITY NUMBER: 414004964
VISIT DATE: 01/16/2025
NARRATIVE
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Home is equipped with a working dual carbon monoxide/smoke detector. LPA observed a fully charged fire extinguisher on kitchen counter. LPA reviewed first aid kit and kit is fully stocked. Helper uses cell phone on the premise. Per helper, there are no weapons or firearms in the home. Per helper, parents provide sheets for sleeping mats and are sent home weekly for laundering or as needed.

LPA reviewed 6 children’s files and 2 staff files. During children’s file review, LPA did not observe signed and completed Acknowledgement of Receipt of Licensing Reports (LIC9224) for 4 currently enrolled children for deficiency cited on October 19, 2023, a type “B” citation is being issued, as this poses a potential health and safety hazard to children in care. LPA reviewed sleeping logs for all infants enrolled. Licensee maintains an updated Children’s roster. H1 CPR/FA expiration date is 4/2025 and Mandated reporter ex. 05/2025. Facility provides meals to children in care, which include breakfast, lunch, and a snack. LPA reminded helper any food brought from home must be labeled and stored properly. LPA observed Childcare License, Emergency Disaster Plan (LIC610A) and Parent's rights posted. Last emergency drill was conducted September 4, 2024, and is properly documented. Licensee carries liability insurance via Acord ex. 10/2025

Helper 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/.

Cont. page 3...
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Maria Olguin-Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
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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: 01/16/2025
NARRATIVE
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Helper 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. LPA's reviewed AB 1207 with the Licensee.

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

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 licensees 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

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

During the exit interview, the HELPER, Caroline Daher confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.



Cont. page 4...
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Maria Olguin-Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SKOBA, SVITLANA
FACILITY NUMBER: 414004964
VISIT DATE: 01/16/2025
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***** THIS IS AN AMENDED REPORT FROM ORIGINAL DATED 01/16/2025 *****

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See page LIC809D for one type “B” deficiency issued today, in accordance with Title 22 Division 12 of the California Code of Regulations.

LPA Maria Olguin-Leon informed helper, Caroline Daher that this report dated January 16, 2025, document(s) one Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

A notice of site visit was given and must remain posted for 30 days. Notice of site visit must be 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 helper, Caroline Daher and Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Carol Marcroft
NAME OF LICENSING PROGRAM ANALYST: Cindy Interiano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2025 03:35 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 01/16/2025 at 02:29 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: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8595(c)(1)
1596.8595(c)(1) A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, licensee did not comply with section cited above, as four enrolled childrens files did not have LIC9224 Acknowledgement of Receipt of Licensing Reports available for deficiency cited on 10/19/2023, as is required for a type “A” deficiency, which is an immediate risk to the health and safety of children in care.
Per LPA file review, C3, C4, C5 and C6 were enrolled within the 12 months of time deficiency was issued.
POC Due Date: 01/23/2025
Plan of Correction
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Helper will provide C3, C4, C5 and C6 parents with report and LIC9224 for visit dated 10/19/2023 for parents to review, complete and sign. Helper will send copies to LPA via email by POC date.
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: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2025 03:35 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 01/16/2025 at 02:56 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: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

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 as there was an adult (H2) working in the home with the children, that did not have a criminal background clearance or associated with facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Per H1, H2 will be sent to be re-fingerprinted and will not return to facility until criminal background clearance has been cleared and associated with facility. POC visit to be conducted.
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: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


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