<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416805
Report Date: 09/11/2024
Date Signed: 09/11/2024 01:35:49 PM

Document Has Been Signed on 09/11/2024 01:35 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:TSYMBALIUK, ALONAFACILITY NUMBER:
434416805
ADMINISTRATOR/
DIRECTOR:		ALONA, TSYMBALIUKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(669) 261-9772
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 14TOTAL ENROLLED CHILDREN: 19CENSUS: 9DATE:
09/11/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:08 PM
MET WITH:Alona TsymbaliukTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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
Licensing Program Analyst (LPA) Marilou Monico met with Licensee, Alona Tsymbaliuk, for a Plan of Correction (POC) inspection. Licensee was cited on August 28, 2024 under Staffing Ratio and Capacity. Also present in the home were licensee's adult assistant, S1, and nine (9) preschool age daycare children.

LPA observed completed and signed Acknowledgement of Receipt of Licensing Report (LIC 9224) in the children's files.

As a result of this inspection, deficiency under Staffing Ratio and Capacity is hereby corrected and cleared.

There were no deficiencies cited.

A Notice of Site Visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1