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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004225
Report Date: 09/18/2025
Date Signed: 09/18/2025 04:27:06 PM

Document Has Been Signed on 09/18/2025 04:27 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:IVANCHYKAVA, ALINAFACILITY NUMBER:
414004225
ADMINISTRATOR/
DIRECTOR:		IVANCHYKAVA, ALINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 730-9214
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 13DATE:
09/18/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Alina IvanchykavaTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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On 9/18/2025 at 1:15PM., Licensing Program Analyst (LPA), Luis Gomez met with Licensee, Alina Ivanchykava. The purpose of today’s visit was explained and was for an unannounced, annual-random inspection. Present in the home was the license and 2 assistants caring for 13 children. (3 infant-age, 9 children preschool age, and 1 school-age). Per licensee, day and hours of operation are Monday- Friday, 8:00AM – 5:30PM. Licensee’s home is a 3 bedroom, 2 bathroom, 2 level house. The areas of the home designated for childcare use are: Lower Level: Living Room (Playroom/ Activity room); Bedroom #1 (Napping Room); Bathroom #1; and Outside Patio. The areas of the home designated as off-limits are: Lower Level: Kitchen; Garage Upper Level: Bedroom #1; Bedroom #2; and Bathroom #2. LPA inspected home with the licensee for health and safety hazards.

At 1:20PM., the following was observed: Facility was clean, neat, with age-appropriate playthings available for the children. The floors and ground surfaces were clear of obstruction or potential hazards. Fireplace area had been barricaded, and added storage is available for children’s belongings.

LPA observed accessible furniture, materials, and blocks were in were in good repair, free of sharp corners. The facility has a table/ chair, scaled to the appropriate size, and infant feeding chairs, with detachable table components and broad base legs.

For scheduled nap, LPA observed napping mats available in Bedroom #1.

LPA advised licensee to ensure napping cribs or play pen is available for infant-age children in care.

Facility bathroom (1) was observed clean with faucet and toilet in operating condition. The detergents, compounds, and other items which can pose a danger have been stored in the off-limit areas. Child safety gates had been installed preventing access to off-limit areas including staircase.

The home had ventilation, lighting, and was comfortable temperature. Facility has a telephone service; smoke/ carbon monoxide, combination detector in hallway, and fire extinguisher (3A:40BC). (REFER TO 809C, FOR CONT.)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
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: IVANCHYKAVA, ALINA
FACILITY NUMBER: 414004225
VISIT DATE: 09/18/2025
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(PAGE 2)
At 1:40PM., LPA inspected the Patio Area. Area was enclosed with tall fencing, and sharp corners have been covered. Structure has been anchored, and plaything were in proper repair.

At 2:00PM., LPA reviewed the facility records including the children’s and staff files. Staff files were reviewed and included the proof of required immunization; Notice of Employee Rights (LIC9052); and Acknowledgement to Report Suspected Child Abuse (LIC9108).

At 2:20PM., Based on Record Review, LPA confirmed staff (S1) proof of immunization missing from the facility files. Advisory Note: Technical Violation (LIC9102TV) was issued.

Children’s files were reviewed and including their: Identification and Emergency Information (LIC700); Notice of Parents Right’s (LIC995A); Consent for Medical Treatment (LIC627).

The licensee is documenting infant napping conditions during each 15 minutes review.

Licensee's Cardiopulmonary / Pediatric First Aid certificates were current, expiring: and 10/2025.

Licensee's required mandated reporter training course, AB1207 was current, 9/2026.

The licensee is conducting emergency disaster drills every 2 years, with the last drill done on 7/1/2025, having been logged.

The required postings were posted in home and include the: License; Emergency Disaster Plan (LIC610); and Notification of Parent’s Rights (PUB379).

Per licensee, isolation of an ill child is in the Playroom.

Licensee was reminded that all adults 18 years and over living in the home, person who provides care and supervision to children, and staff who have contact with children, including employee and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain criminal 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.


(REFER TO 809C, FOR CONT.)
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
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)
Page: 4 of 5
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: IVANCHYKAVA, ALINA
FACILITY NUMBER: 414004225
VISIT DATE: 09/18/2025
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(Page 3)
LPA discussed safe sleep regulations with licensee and the Child Care Licensing Safe Sleep Web page at:https://www.cdss.ca.gov/inforesource/child-care-licesning/public-information-and-resources/safe-sleep as an additional resource. LPA informed licensee of the importance of checking for recalled infant devices on United States consumer Product Safety Commission (CPSC) website at http://www.cpsc.gov and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

For IMS information, see PIN 20-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll- free ADA information line at (800) 514-0301 (voice)/ (800) 514- 0382 (TTY) and link to publications: Commonly asked questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

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 tool, please send them 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/inforesource/community-care-licensing/inspection-process.

Based on today's inspection, no deficiencies were cited in areas evaluated, according to Title 22, Div. 12 Chap. 3, CA Health and Safety Code of Regulations. An exit interview and facility evaluation reports were discussed with Licensee, Alina Ivanchykava. The signature of this form acknowledges receipt of these documents.

During exit interview, the licensee confirmed no registered sex offenders are living in the facility, and LPA completed RSO profile in FAS. Notice of the Site visit was provided and must remain posted for 30 days.

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
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)
Page: 5 of 5