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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005057
Report Date: 09/30/2024
Date Signed: 09/30/2024 10:14:47 AM

Document Has Been Signed on 09/30/2024 10:14 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, 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:
09/30/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Viktoria Volksonska-SimonTIME VISIT/
INSPECTION COMPLETED:
10:40 AM
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On September 30th, 2024, at approximately 9:30 AM, Licensing Program Analyst (LPA) Janet Gil conducted an unannounced, plan of correction (POC) visit. LPA met with licensee,Viktoria Volksonska-Simon, and explained the purpose of the visit. Present during today's visit included licensee, assistant, and 9 enrolled children.

On September 23, 2024, at approximately 2:00 PM, LPA Gil conducted an unannounced, annual inspection. During annual inspection, licensee was issued one Type A citation for operating over licensed capacity limits, operating with 4 infants (under 24 months), and 5 preschoolers with no assistant present. A POC was discussed with licensee.

As of this date, LPA observed licensee to be operating with 9 children (4 infants and 5 preschoolers) with support of an assistant. All children's files have a signed Acknowledgement of Receipt of Licensing Reports (LIC 9224) signed properly by parents or authorized representatives. During visit, LPA also observed Notice of Site Visit to be properly posted and available for review.

LPA confirmed licensee to be operating within licensed capacity limits on this date.

Deficiencies cited on September 23, 2024, have been cleared during today's visit. LPA provided licensee with POC letter. No deficiencies were cited today.

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

Exit interview conducted and report was reviewed with licensee, Viktoria Volksonska-Simon.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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