414005057-11-15-2023-05-CC-MTSO-CXLQBD-20231115110121

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414005057
Report Date: 11/15/2023
Date Signed: 11/15/2023 11:01:36 AM

Document Has Been Signed on 11/15/2023 11:01 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	VOLKONSKA-SIMONYAN, VIKTORIIA		FACILITY NUMBER:	414005057
ADMINISTRATOR:	VIKTORIIA VOLKSONSKA-SIMON		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 801-3333
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	11/15/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:22 AM
MET WITH:	Viktoriia Volkonska-Simonyan		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On November 15, 2023, Licensing Program Analyst (LPA) Tso met with the Applicant, Viktoriia Volkonska-Simonyan, for an announced pre-licensing inspection. Licensing Program Manager (LPM) Zebila joined during the visit. The applicant was present at the home. The applicant rents this one-floor unit, consisting of three bedrooms, an office, two bathrooms, a living room, a dining room, a kitchen, a garage, and backyard. The home residents are the applicant and her two children (minors). The childcare area will be provided in the living room, bathroom # 2, dining room and backyard. The off-limit areas are the three bedrooms # 1,2 & 3, office, kitchen, bathroom #1 and garage. The days and hours of operation will be Monday - Friday, 8:00 am to 5:00 pm, and care for preschoolers. Per the Applicant, she plans to utilize the dining room as an isolation for sick/ill children. LPA, LPM and the Applicant inspected the entire home for Health and Safety Hazards. The house is clean and orderly and has sufficient lighting and ventilation. LPA observed three cribs and 12 cots in the bedroom #3. Per the licensee, the cribs would not be used as not intend to care infants. LPA reminded the applicant to keep cribs free of toys, pillows, and hanging objects. Mattresses must be designed for playpens, and bed sheets should fit tightly. There are a variety of age-appropriate toys for the children. All furniture and playthings were observed to be in good repair. The home has multiple smoke detectors, combination smoke & carbon monoxide detectors. During the inspection, all detectors were tested and worked. All harmful objects, sharp objects, and toxins are stored out of the reach of children and made inaccessible to children. The Applicant states that no weapons, firearms, or pets are in the home. The home has no body of water, such as a swimming pool, spa, hot tub, or fishpond. All unused electrical outlets and electrical wires/power surges were observed covered. The fireplace was barricaded. Continued on page 2...

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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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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: VOLKONSKA-SIMONYAN, VIKTORIIA	FACILITY NUMBER: 414005057
	VISIT DATE: 11/15/2023

NARRATIVE

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LPA informed the Applicant that emergency drills are required every six months, and the Applicant must document the drills. The Applicant reminded that NO baby walkers, exer-saucers, jumpers, bouncers, and similar items are to be used for children in care and should be made inaccessible. In addition, booster chairs are only used for the purpose of feeding/eating. The Applicant was also reminded that smoking is prohibited at the daycare.

The Applicant plans to provide the children breakfast, lunch, and morning & afternoon snacks. Per the Applicant, she intends to purchase liability insurance for childcare. LPA informed the Applicant that if childcare insurance is not purchased, each parent must be given the Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282). Applicant's Pediatric FirstAid CPR and Mandated Reporter Training are valid, and copies have been submitted to the Department.

LPA reviewed with the Applicant the LIC 311D, Forms/Records to Keep in Your Family Child Care Homes, children's forms/records, facility forms/records, and all required postings such as License/Parent's Right poster/Emergency Disaster Plan and Earthquake Preparedness checklist. In addition, the entrance Checklist was also provided to the Applicant. The Applicant plans to have all required posting on the left wall by the living room. License capacity and limitation were also reviewed with the Applicant. LPA informed the Applicant that if care is provided to the 13th and 14th child, who must be school-aged, parent notification and landlord consent are required.

LPA discussed the safe sleep regulations with the Applicant and discussed the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the 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.

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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: VOLKONSKA-SIMONYAN, VIKTORIIA	FACILITY NUMBER: 414005057
	VISIT DATE: 11/15/2023

NARRATIVE

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The 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, 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.

The applicant has not obtained a signed Property Owner/Landlord Consent form (LIC9149). Without this consent, the applicant understands that, once licensed, they can operate with a maximum capacity of 12 children. If property owner/landlord consent is obtained in the future, the applicant is advised that a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 14 children.

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) or (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.
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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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: VOLKONSKA-SIMONYAN, VIKTORIIA	FACILITY NUMBER: 414005057
	VISIT DATE: 11/15/2023

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The Applicant was reminded 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. The Applicant was encouraged to obtain a copy of regulations and current licensing forms through the Department's website at www.ccld.ca.gov. The Applicant was also reminded of Mandated Reporter Online Training for Child Care Providers (AB 1207) and the additional General Training, and both are available on www.mandatedreporteca.com.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders through Provider Information Notices (PIN), Program Quarterly Update Newsletters, and other important information communication platforms. 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.

The applicant 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.

The Central County Fire Department issued a fire clearance for the home on 10/27/2023, as necessary for a Large Family Child Care Home.

Prior to licensure, the following issue must be addressed.
· Provide proof of a criminal record clearance.

The report was reviewed and signed by the Applicant, Viktoriia Volkonska-Simonyan. Today's report was provided to the Applicant. This report will be kept in the facility file and available for public review upon request. Desk duty is available Monday - Friday, 8:00 a.m. – 5:00 p.m. (650) 266-8800. Website for Forms and Regulations: www.cdss.ca.gov

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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