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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191203519
Report Date: 01/08/2020
Date Signed: 01/08/2020 02:36:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:ST MARY'S ARMENIAN SCHOOLFACILITY NUMBER:
191203519
ADMINISTRATOR:AGHAZARIAN, ARSINEFACILITY TYPE:
850
ADDRESS:1200 E CARLTON DRIVETELEPHONE:
(818) 240-7030
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:200CENSUS: 181DATE:
01/08/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Arsine Aghazarian, DirectorTIME COMPLETED:
02:50 PM
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Licensing Program Analysts (LPA) Anomeh Eivazian and Katrina Chicote conducted an unannounced case management inspection today, due to an incident that occurred on Tuesday, May 14, 2019. LPAs met with Arsine Aghazarian, Director.

Alleged Incident took place on 05/14/19. Incident was reported via telephone same working day. Original LIC 624 Unusual Incident/Injury Report form was received by the Department within 7 days. The written incident report was received by fax on 05/21/19. The incident report was dated for 05/21/19. The facility reported the incident within the required 24 hour time frame.

LPA Eivazian observed the area where alleged incident took place. LPA Eivazian conducted an interview with Director. Per Director, child #1 informed parent that while child#1 was playing outside, child#2 pulled pants in an appropriate manner while playing with the puppet stand. Per director a meeting was held with both parents. Both children were interviewed and no disclosures were made. Child#1 and Child#2 were separated immediately. Teachers on that classrooms were interviewed by director and no disclosure were made. Facility camera footage were checked by school director and noting was captured in the camera footage. Director notified Child Protective Services and was told it was not a reportable incident. Both children still are attending this school. Director held a meeting for all staff with Community Care Licensing Advocate, Shoghig Khodarian on 05/09/19 regarding Care and Supervision.

At this time, there is not a preponderance of evidence that shows that the facility was in violation with Title 22 Regulations when the incident occurred. Therefore, there are no deficiencies being cited. The Notice of Site Visit (LIC 9213)must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview was conducted with Arsine Aghazarian, Director, including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 854-8930
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020
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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