414005161-4-30-2025-05-CC-KKRN-DG7PJN-20250429112145

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414005161
Report Date: 04/29/2025
Date Signed: 04/30/2025 10:10:02 AM

Document Has Been Signed on 04/30/2025 10:10 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:	DONTOVA, NATALIA		FACILITY NUMBER:	414005161
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 5	DATE:	04/29/2025
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Natalia Dontova		TIME VISIT/ INSPECTION COMPLETED:	11:45 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 April 29, 2025 at approximately 8:30AM Licensing Program Analyst (LPA) Katie Krenn conducted an unannounced case management visit at the facility. LPA met with Licensee, Natalia Dontova and explained the purpose of the visit. Present during the visit was Licensee, one helper, and five children (three infants and two preschool children). The licensee currently has a small license and is operating within the capacity limits and ratios during today's visit. Licensee submitted an application for an increase in capacity. Fire clearance was granted on April 22, 2025. With applicant, LPA inspected the entire home, inside and outside, for health and safety hazards. The home is a one level home that consists of 3 bedrooms and 2 bathrooms. LPA did not observe any pools, spas, or bodies of water on the property. DAY CARE AREAS the living room (main play area), bedroom #2 (napping room), bedroom #3 (planned additional napping area), bathroom #2, the backyard, and an accessory dwelling unit (classroom). OFF LIMIT AREAS the kitchen, dining room, bedroom #1, bathroom #1, and garage. Off limit areas are made inaccessible with child safety door handles and installed child safety gates. LPA observed that all required documents, such as the facility license, the Notification of Parental Rights, and the Earthquake Preparedness Checklist, were displayed and visible to the public. LPA observed the day care area to be clean and safe. Day care areas were observed to be equipped with a variety of toys, materials and furniture that were age appropriate. LPA observed electrical outlets made inaccessible with safety covers. LPA observed that the fireplace was made inaccessible with furniture. continued on page 2

NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025

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: DONTOVA, NATALIA	FACILITY NUMBER: 414005161
	VISIT DATE: 04/29/2025

NARRATIVE

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LPA and Licensee inspected the home for any health or safety hazards. There is a fully charged 2A10BC fire
extinguisher, a fully stocked first aid kit, and a backpack with emergency evacuation supplies present in the home. LPA observed combination smoke and carbon monoxide detectors in all the indoor daycare areas. Electrical outlets are covered or blocked by furniture when not in use. Poisons, cleaning detergents, and other chemicals are stored inaccessible to children in care.

This facility provides breakfast, lunch, dinner, and snacks. LPA reviewed a copy of the menu and saw that it included fruits, vegetables, and whole grains. Per licensee, menus are provided weekly to parents.

The backyard is surrounded by a fence and features a variety of outdoor play equipment, all of which are in excellent condition. The areas around and under high climbing equipment, swings, slides, and similar equipment were observed to be cushioned with artificial grass. A portion of the backyard area is shaded.

LPA reviewed children's files and found all the required documents. LPA reviewed the staff files and found all required documents. LPA reminded licensee that all staff must do the Childcare Mandated Report Training every two years and that CPR/First Aid also must be renewed every two years.

LPA discussed capacity and ratio requirements for a large Family Child Care Home (FCCH) with Licensee
during the visit. Licensee is aware that if a helper is not present, they must comply with the capacity and ratio
requirements of a small FCCH. LPA also discussed Safe Sleep Requirements, Discipline Policy, Medications, Allergies, and Disaster Drills. LPA reminded applicant emergency disaster drills are to be conducted and documented at least once every six months.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025

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: DONTOVA, NATALIA	FACILITY NUMBER: 414005161
	VISIT DATE: 04/29/2025

NARRATIVE

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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 [facility representative] 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.

Licensee was reminded that all adults 18 and over living or working in the home, 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 to recommend approval of a large license effective April 29, 2025.
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No deficiencies were cited during today's visit. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Licensee, Natalia Dontova.

NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025

LIC809 (FAS) - (06/04)

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