414005263-7-24-2025-05-CC-KKRN-DJVNXR-20250724105133

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414005263
Report Date: 07/24/2025
Date Signed: 07/24/2025 10:52:09 AM

Document Has Been Signed on 07/24/2025 10:52 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:	MISHYNA, HULIZAR		FACILITY NUMBER:	414005263
ADMINISTRATOR/ DIRECTOR:	MISHYNA, HULIZAR		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 937-4543
CITY:	MENLO PARK	STATE: CA	ZIP CODE:	94025
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	07/24/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Hulizar Mishyna		TIME VISIT/ INSPECTION COMPLETED:	11:15 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 July 24, 2025, at approximately 8:30AM, Licensing Program Analyst (LPA) Katie Krenn conducted a scheduled pre-licensing visit at the address listed above. LPA met with Applicant, Hulizar Mishyna explained the purpose of the visit. Applicant has applied for a large Family Child Care Home License. Currently, the applicant’s planned operating hours will be from 8:00AM to 6:00PM, Monday to Friday. All adults living in the home have received fingerprint clearance. Applicant rents the home and has received landlord consent to have a large daycare in the home. Daycare Areas: Living Room, Bedroom #1, Bedroom #2, Bathroom #1, and Backyard. Off-Limits Areas: Kitchen, Family Room, Dining Area, Front Yard, Driveway, Garage, and entire second level of the home, which includes 2 bedrooms and 2 bathrooms. Applicant confirmed that there are no swimming pools, spas, or other similar bodies of water present. LPA verified that Applicant’s phone number and email address were current during the visit. LPA and Applicant inspected the home for any health or safety hazards. LPA observed that all necessary postings such as the Notification of Parent's Rights Poster (PUB 394), the Earthquake Preparedness Check List (LIC9148), and the Emergency Disaster Plan (LIC 610A) were posted at the entrance where children will be dropped off and picked up by their caregivers. LPA observed there to be a fully charged fire 3A40BC fire extinguisher. LPA observed and tested a smoke detector alarm and a separate carbon monoxide alarm. LPA found both of them to be functioning properly. The fire place was appropriately covered. LPA observed the living room to have age appropriate furniture, toys, and educational materials, all of which were clean and in excellent condition. Portions of the floor are covered with mats and rugs. continued on page 2

NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025

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: MISHYNA, HULIZAR	FACILITY NUMBER: 414005263
	VISIT DATE: 07/24/2025

NARRATIVE

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LPA observed that the electrical outlets were covered to prevent children’s access. LPA also observed that child safety locks had been used to prevent children from accessing doors. LPA observed that child safety gates were being used to prevent children's access to stairs, the second level, and other off-limits areas.

LPA observed that bathroom #1 was clean and had suitable toileting materials. LPA observed that accessible drawers and cabinets were free of hazardous materials and toxic substances.

Both bedrooms #1 and #2 had five toddler sized beds with appropriate bedding and one crib with well fitted mattresses and tightly fitting sheets in each room for a total of two cribs and ten toddler beds. LPA reminded Applicant that that nothing can be in the crib with the infant, nothing can be attached to a pacifier, sheets must be tightly fitted, and infants should not be swaddled or in a sleep sack. Applicant stated that they understood.

Applicant stated that they plan to offer breakfast, lunch, snack, and dinner. LPA observed a posted weekly menu and daily activity schedule. LPA discussed food storage, food allergies, and storage of medication. Medication shall be stored in a central location that is inaccessible to children in care, be clearly labeled for each child, and will have clear written instructions for administering medication. Applicant stated that use of medication will be discussed with parents.

LPA observed the backyard to be enclosed by a fence that is at least 5 feet high. There are age-appropriate play structures, play house, and other outdoor toys available. The outdoor play area is covered with artificial grass. LPA reminded Applicant that artificial grass can get hot, so it is important to check to see if it is hot before children play on it. Applicant stated that they understood. LPA observed all furnishings to be in excellent condition and suitable for preschool children.

LPA reviewed Applicant’s records and found that their Mandated Reporter Training (MRT) and Pediatric First Aid/CPR training are current. Applicant used an EMSA approved training program. LPA reminded Applicant that both the MRT and First Aid/CPR need to be renewed every two years and that current copies need to be available for review. Applicant stated that they understood.

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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025

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: MISHYNA, HULIZAR	FACILITY NUMBER: 414005263
	VISIT DATE: 07/24/2025

NARRATIVE

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LPA discussed with Applicant the requirement to be present in the home ensuring that children are supervised. In the event of a temporary absence, Licensee shall arrange for a substitute adult to provide care and supervision for children. A suitable adult shall have fingerprint clearance, MRT certification, and First Aid/CPR. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. Applicant stated that they understood.

The Applicant has obtained a signed Property Owner/Landlord Consent form (LIC9149). Applicant is only requesting a capacity of 12 children. The applicant is advised that if they want to change their capacity then a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 14 children. LPA informed applicant that their own children under the age of ten years old, would be included in the capacity. Applicant stated that they understood.

LPA reviewed the pre-licensing packet with the Applicant going over all the required postings, required forms, and paperwork. Copies of required forms and Entrance Checklist was provided to the applicant. LPA reviewed the ratio and capacity of a small and large family child care home license. Applicant submitted some additional documentation that the LPA had requested.

Applicant plans to have liability insurance. LPA informed applicant that if they do not get liability insurance, then parents must sign the Affidavit Regarding Liability Insurance (LIC 282). Applicant stated that they understood.

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

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025

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: MISHYNA, HULIZAR	FACILITY NUMBER: 414005263
	VISIT DATE: 07/24/2025

NARRATIVE

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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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

LPA discussed the safe sleep regulations with applicant 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 applicant 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.

Applicant was informed of the MyChildCarePlan.org site, 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/ subscribe and select the Child Care option to receive email communication.

LPA has approved this Family Child Care Home for Licensure.

Exit interview conducted and report was reviewed with the applicant, Hulizar Mishyna.

NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025

LIC809 (FAS) - (06/04)

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