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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004967
Report Date: 12/05/2022
Date Signed: 12/05/2022 09:58:20 AM

Document Has Been Signed on 12/05/2022 09:58 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:VOLKONSKA, VIKTORIIAFACILITY NUMBER:
414004967
ADMINISTRATOR:VOLKONSKA, VIKTORIIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 801-3333
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 0DATE:
12/05/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:VIktoriia VolkonskaTIME COMPLETED:
10:15 AM
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On December 5, 2022 at approximately 8:30am, Licensing Program Analyst (LPA) Catrina Quimbo conducted a scheduled, pre-licensing inspection. LPA met with licensee, Viktoriia Volkonska, and explained the purpose of the visit. Present during LPA's visit included licensee and licensee's mother. Licensee is currently licensed (Fac # 414004761). Licensee applied for a relocation 11/04/2022. Home received an updated fire clearance 11/18/2022.

With licensee, LPA conducted a health and safety inspection, inside and outside the home. Licensee rents the home with their mother. Proof of control of property was provided to department.

The home is a single level, single family home that includes 3 bedrooms, 2 bathrooms, living room, kitchen, family room, backyard and garage. The DAY CARE AREAS are the living room (main classroom), family room, bathroom #1, bedroom #2 (napping room), right side of the backyard (when exiting the home). The OFF LIMIT AREAS are the kitchen, bedroom #1, master bedroom, bathroom #2 (located in master bedroom), left side of the backyard and garage. Kitchen was observed to be made inaccessible with a child safety gate.

LPA observed the home to be clean and safe, with multiple dual smoke and carbon monoxide detectors, multiple fully charged fire extinguisher and fully equipped first aid kit. Licensee will continue to use a designated cell phone and is aware the phone must stay within the home during the day care hours. LPA observed the home to be equipped with appropriate toys and materials, that were new and/or in good working condition. LPA observed electrical outlets in day care areas to be made inaccessible with child safety covers. The home contains 2 fireplaces (located in living room and family room), that have been made inaccessible, blocked by furniture. LPA observed poison and other chemicals to be stored in kitchen, made inaccessible with child safety locks.
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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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: VOLKONSKA, VIKTORIIA
FACILITY NUMBER: 414004967
VISIT DATE: 12/05/2022
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Entire backyard is enclosed with an at least 5 ft. high fence. LPA observed outdoor area to have appropriate equipment that were in good working condition. Upon exiting the home, the right side of the backyard (with grass) is a day care area while the left side of the backyard (stepping stones) is an off limit area. LPA observed licensee to have made the left of the backyard inaccessible, by blocking the space with children's materials and a child safety gate. Day care area of backyard was observed to have grass and artificial turf. LPA did not observe any pools, spas, bodies of water or additional living spaces on the home's property.

Per licensee, there are no firearms, weapons or pets in the home. Licensee was reminded baby walkers, bouncers, jumpers and any other similar items are not to be used for children in care. LPA did not observe bathroom #1 to have any accessible poisonous or hazardous materials to be stored. Licensee will continue to provide cribs, cots and sheets for napping children in care. Licensee maintains safe sleep logs on application via mobile phone. Safe sleep regulations, COVID-19 guidelines and laundering were discussed. LPA reminded licensee emergency drills are to be conducted and documented once every six months. Licensee is aware that prior to use of any off limit area, the department must be notified and must approve the space.

Required documents are posted and available for review upon entering the home. Licensee's CPR and First Aid training certificate will expire 09/2023.

Licensee 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 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. LPA also informed licensee 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.
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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
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: VOLKONSKA, VIKTORIIA
FACILITY NUMBER: 414004967
VISIT DATE: 12/05/2022
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LPA reviewed with licensee 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.

This facility plans to provide Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

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.

During inspection, licensee provided LPA with copy of licensee's mother's updated TB clearance.

Prior to recommended licensure, following must be completed:
-Installation of child safety door handles to off limit bedrooms and garage.
-Installation of additional padding on fire place bricks located in family room.
-Inaccessibility of rocks located in day care area in backyard.
-Renewal of licensee's Mandated Reporter training certificate.
-Licensee is fully moved into new home.

Exit interview conducted and report was reviewed with the licensee, Viktoriia Volkonska.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC809 (FAS) - (06/04)
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