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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413945
Report Date: 08/23/2021
Date Signed: 08/23/2021 02:50:55 PM

Document Has Been Signed on 08/23/2021 02:50 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:VENZON, NATALYAFACILITY NUMBER:
434413945
ADMINISTRATOR:VENZON, NATALYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 603-5656
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/23/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Natalya VenzonTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Pete Hernandez met with Licensee Natalya Venzom and Assisitant Ianina Titoruk and conducted Required 1 Year inspection continuance.

The purpose of the continuance is to review the staff and children's files that were not available at the time of the first visit. (The Licensee was away on vacation at the first time of the visit.)

LPA Reviewed 3 staff files and all of the required documentation was available.
CPR first aid courses are all current and do not expire until 2/28/2022.
Last Fire Drill was done on 7/30/2021.

Licensee provided a current copy of the children's roster to the LPA.

LPA reviewed 6 of 12 children that normally attend. All files were complete with the required documentation and in good order.

LPA/s discussed the requirements of AB 633 with the Licensee/Director (provide name) and provided the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and the Licensee/Director understands the requirements. Upon receipt, Licensee/Director (provide name) shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

Continued on page 2 of 809C dated 8/23/2021
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2021
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: VENZON, NATALYA
FACILITY NUMBER: 434413945
VISIT DATE: 08/23/2021
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LPA/s also discussed "zero tolerance" related regulations with the Licensee/Director, (provide name) and was advised of the assessment for an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

A deficiency is NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted. A copy of this report was discussed and left with the Licensee, Natalya Venzon, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021
LIC809 (FAS) - (06/04)
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