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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434402845
Report Date: 03/23/2022
Date Signed: 03/24/2022 09:24:56 AM

Document Has Been Signed on 03/24/2022 09:24 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:JABLONSKY,IRINA & ZANVEL,BORISFACILITY NUMBER:
434402845
ADMINISTRATOR:JABLONSKY,IRINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 554-7223
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
03/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Boris ZanvelTIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst(LPA) Anna Morales conducted a CASE MANAGEMENT visit and was greeted by Licensee Boris Zanvel. Licensee has requested an extension of their INACTIVE STATUS.

LPA toured the facility and observed a Carbon Monoxide, smoke detector and a charged Fire Extinguisher. Licensee stated that he will be sending a copy of their First Aid/ CPR AID CARD. LPA did not observe any children in care.

No deficiencies were cited at today's visit. LPA obtained a signed copy of a LIC9211 (REQUEST FOR INACTIVE CHILD CARE LICENSE STATUS) during today's visit.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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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