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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005057
Report Date: 09/18/2025
Date Signed: 09/18/2025 04:38:02 PM

Document Has Been Signed on 09/18/2025 04:38 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: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: 11CENSUS: 11DATE:
09/18/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Licensee, Viktoriia Volkonska-SimonyanTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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On 9/18/2025, at approximately 2:30PM, Licensing Program Analysts (LPAs) Jonathan Tse and Nicole Tran conducted an unannounced annual visit. LPAs met with Licensee, Viktoriia Volkonska-Simonyan, and explained the purpose of the visit. Present during the visit was Licensee, a helper, 4 infants, and 7 preschool-age children. The facility is operating within staffing and ratio requirements on this day. The facility’s operating hours are 8:00AM to 5:30PM, Monday to Friday.

Daycare Areas: Living Room, Dining Room, Bathroom #2, and Backyard.
Off-limits Areas: Bedroom #1, Bedroom #2, Bedroom #3, Office, Kitchen, Bathroom #1, and Garage.

LPAs and Licensee inspected the home for any health or safety hazards. There is a fully charged 2A10BC fire extinguisher present in the facility. There are carbon monoxide detectors present that are operational. There is a fireplace in the Living Room that is covered to be inaccessible to children in care. Outlets are covered or blocked by furniture when not in use. Poisons, cleaning detergents, and other chemicals are stored inaccessible to children in care. Off-limits areas are secured with childproof gates.

LPAs observed there to be age-appropriate toys and learning materials present. Furniture is age-appropriate and free of rough or sharp edges. Cubbies are available for children to use as storage. The facility provides cots for children to nap on. Sheets are washed once a week. Per Licensee, they provide breakfast, lunch, and AM/PM snacks for children in care. The facility accommodates children’s dietary needs and preferences. Water bottles are provided from home and are refilled at the facility.

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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/18/2025
NARRATIVE
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The Backyard was observed to be enclosed by a fence that is at least four feet high. There are age-appropriate toys and equipment present. There are two pet dogs present in the facility. Per Licensee, families are provided notice that dogs are present in the home. There are no swimming pools or other similar bodies of water present. Per Licensee, there are no firearms or weapons stored in the home.

LPAs reviewed two staff files, 11 children’s files, and facility records. Licensee’s Pediatric First Aid/CPR training expires 8/2027. Licensee’s Mandated Reporter Training expired 12/2024. Licensee stated that they were working on completing the training. Licensee completed the training during the visit. LPAs advised that immunization records (MMR, pertussis) shall be maintained in each staff member’s file.

LPAs observed children’s files to contain Emergency Identification and Information (LIC700) and immunization records. The facility was cited a Type A deficiency on 9/23/2024. Based on review of children’s files, 5 children’s files did not have a signed Acknowledgement of Receipt of Licensing Report (LIC9224). LPA advised that all children enrolled before 9/23/2025 must have a signed LIC9224 on file. Infant sleep logs are maintained.

Based on observation and review of facility records, LPAs found that the facility is currently using Bedroom #2 as an infant napping room. Bedroom #2 was not approved for use by the Department. LPAs advised that Licensee shall submit an updated application (LIC279), a written letter of intent, a facility sketch (LIC999), and an updated Emergency Disaster Plan (LIC610A) to add Bedroom #2 to the daycare areas.

All required postings are posted and accessible for review immediately upon entry to the home. Licensee carries liability insurance. The facility last conducted an emergency drill on 8/11/2025. Emergency drills are properly logged and documented.

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.
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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
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: VOLKONSKA-SIMONYAN, VIKTORIIA
FACILITY NUMBER: 414005057
VISIT DATE: 09/18/2025
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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.

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-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 child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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

See LIC809-D for deficiencies cited today regarding daycare areas and child’s records. See LIC9102-TV for technical violation issued today regarding Mandated Reporter Training. Appeal rights were provided and explained.

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

Exit interview conducted and report was reviewed with the Licensee, Viktoriia Volkonska-Simonyan.
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/18/2025 04:38 PM - It Cannot Be Edited


Created By: Jonathan Tse On 09/18/2025 at 04:08 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: 09/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by using Bedroom #2 as a daycare area without notifing the Department which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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Licensee shall mail the following to LPA: LIC279 (check off "update"), a letter of intent stating which rooms will be added as daycare areas, an updated facility sketch (LIC999), and an updated emergency disaster plan (LIC610A).
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.
Ali Zebila
NAME OF LICENSING PROGRAM MANAGER:
Jonathan Tse
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2025


LIC809 (FAS) - (06/04)
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