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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274416254
Report Date: 06/27/2024
Date Signed: 06/27/2024 07:52:47 PM

Document Has Been Signed on 06/27/2024 07:52 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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MATROSOVA-KHALIL, SOFIAFACILITY NUMBER:
274416254
ADMINISTRATOR/
DIRECTOR:		SOFIA MATROSOVA-KHALILFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 277-4352
CITY:SEASIDESTATE: CAZIP CODE:
93955
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
06/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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June 27th 2024 , Licensing Program Analyst (LPA), Andrea Cortez met with Licensee, Sofia Matrosova-Khalil for a case management inspection to address food prep, hand/bathroom washing sink, and current roster.

LPA addressed concerns with licensee. The licensee responsibility ensuring the safety and hygiene of the food preparation area.The current setup includes a refrigerator, an electric stove top for warming food, and limited counter space, which is supplemented by a toy kitchen. Additionally, plastic dishes and cups are placed near the hand wash sink and toilet, which may pose a risk across contamination. It is crucial to ensure that the food preparation area is adequately sanitized and free from vermin, and that the childcare room is free from any defects or conditions that could endanger the children.

In addition LPA cited for current roster. LPA explained the essential reasons to maintain a current roster of all children under care at the facility. The roster should include each child's name, address, and daytime telephone number of their parent or guardian, as well as the name and telephone number of the child's physician. This roster must be readily available for review by the licensing agency upon request.

LPA cited: 1596.841 and 102417(g)
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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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Document Has Been Signed on 06/27/2024 07:52 PM - It Cannot Be Edited


Created By: Andrea Cortez On 06/27/2024 at 02:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MATROSOVA-KHALIL, SOFIA
FACILITY NUMBER: 274416254

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2024
Section Cited
HSC
102417(g)

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The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to: one sink used for food prep and hand wash (after bathroom use)
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Plan as to where food prep and dishes will be washed and sanitized
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Based on observation on June 18th 2024 the licensees did not comply with the section 102417. Which poses a potential health and safety risk to persons in care.
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Type B
06/27/2024
Section Cited
HSC1596.841

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Each family child care home shall have a current roster of children as specified in Health and Safety Code Section
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Complete roster for each child and email to LPA
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Roster to enclude child's full name, address, phone of a parent or other responsible adult. And the name and telephone number of the child's physician
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Gladys Kuizon
LICENSING EVALUATOR NAME:Andrea Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


LIC809 (FAS) - (06/04)
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