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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005057
Report Date: 09/23/2024
Date Signed: 09/23/2024 03:42:29 PM

Document Has Been Signed on 09/23/2024 03:42 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:VOLKONSKA-SIMONYAN, VIKTORIIAFACILITY NUMBER:
414005057
ADMINISTRATOR/
DIRECTOR:		VIKTORIIA VOLKSONSKA-SIMONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 801-3333
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
09/23/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:01 PM
MET WITH:Viktoria Volkonska-SimonyanTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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On September 23, 2024, at approximately 2:00 PM, Licensing Program Analyst (LPA) Janet Gil conducted an unannounced, annual inspection. LPA met with licensee, Viktoria Volkonska-Simonyan, and explained the purpose of the inspection. Present during LPA’s visit included licensee, and 9 enrolled children (4 infants and 5 preschoolers). The licensee is a large license and is not operating within capacity limits and ratio. Per licensee, her assistant staff is out sick. Type A deficiency is being issued on this day in accordance with the California Code of Regulations, Title 22, see LIC 809D.

Licensee rents home, which is a 3 bedrooms, 2 bathroom, single level home. Licensee lives in home with two minor children. All adults living and working in the home have fingerprint clearance. Facility operates Monday Through Friday 8:00 AM to 5:00 PM.

Day Care Areas: Living room, Bedroom #2, Bathroom # 2, Dining Room and Backyard.

Off Limit Areas: Bedrooms # 1,& 3, Office, Kitchen, Bathroom #1 and Garage

At approximately 2:30 PM, LPA toured day care areas of home with licensee. LPA observed the home to be in good repair with proper temperature and ventilation. Home is equipped with a variety of toys and materials that were observed to be in working condition. LPA observed a fully stocked accessible first aid kit located in the kitchen area. LPA did not observe any accessible cleaning supplies, poisons, and solutions in day care areas. LPA observed electrical outlets to be made inaccessible with outlet covers. Home is equipped with a fully charged fire extinguisher and multiple smoke and carbon monoxide detectors. Licensee does not have any children in care with allergies or IMS plans. Per licensee, she provides all foods for the children in care.

At approximately 2:45 PM, LPA observed bathroom for children's use was in proper working condition. LPA observed bathroom to include appropriate toileting equipment and sanitation products. LPA did not observe any hazardous materials to be accessible to children in the bathroom.

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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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: 09/23/2024
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The entire backyard is fully enclosed. The outdoor area is equipped with a variety of toys and materials. LPA did not observe any pools, spas, or bodies of water in day care areas.

LPA reviewed five children records which were complete. The children’s files have a record of emergency identification information and required immunization. LPA reviewed staff records for licensee which were complete. Licensee's CPR/FIrst Aid is current and will expire 09/27/2025. The licensee’s Mandated Reporter training certification is also current and will expire 12/6/2024. The licensee also has required immunization available for review.

Licensee has licensing documentation properly posted and available for review. The licensee also maintains a childcare roster that was made available for review. Emergency disaster drills are conducted at least once every six months. The last disaster drill was conducted on June 28th, 2024. Per licensee, there are no weapons or firearms in the home.

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 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.

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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
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: 09/23/2024
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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.

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

On this date, 9/18/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

LPA Gil informed licensee Viktoria Volkonska-Simonyan that this report dated 9/23/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Gil informed the licensee Viktoria Volkonska-Simonyan to provide a copy of this licensing report dated 9/23/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.



Exit interview conducted and report was reviewed with the licensee, Viktoria Volkonska-Simonyan.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/23/2024 03:42 PM - It Cannot Be Edited


Created By: Janet Gil On 09/23/2024 at 03:22 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: VOLKONSKA-SIMONYAN, VIKTORIIA
FACILITY NUMBER: 414005057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having a present assistant with a large licensed capacity which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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Per licensee, assistant was out sick and back up assistant was on vacation. Licensee will ensure to have present assistant or operate as a small license.
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:Garfield Leung
LICENSING EVALUATOR NAME:Janet Gil
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024


LIC809 (FAS) - (06/04)
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