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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191203519
Report Date: 11/03/2022
Date Signed: 11/03/2022 02:20:22 PM


Document Has Been Signed on 11/03/2022 02:20 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:ST MARY'S ARMENIAN SCHOOLFACILITY NUMBER:
191203519
ADMINISTRATOR:AVANESSIAN, LORETTEFACILITY TYPE:
850
ADDRESS:1200 E CARLTON DRIVETELEPHONE:
(818) 240-7030
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:200CENSUS: 159DATE:
11/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Lorette Avanessian, DirectorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced case management inspection today at 11/03/2022 due to an incident that occurred on Tuesday, August 23, 2022. LPA met with Lorette Avanessian, Director who guided analyst on a tour of the facility.

Alleged Incident took place on 08/23/2022. Incident was reported via email next 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 email on Wednesday 08/24/22. The facility reported the incident within the required 24 hour time frame.

LPA observed the area where alleged incident took place. LPA conducted interviews with staff #1, staff#2 staff #3, and child#1. LPA watched video footage for 08/23/22 from the area where alleged incident occurred.

Per staff # 2, who was present outside when alleged incident occurred on 08/23/22, no disclosures were made. Per staff#2, did not observe staff#1 to pinch child #1 or any other children on 08/23/22 or at anytime.

Based on an interview that was conducted with child#1 on 11/03/22, no disclosures were made.

Based on a phone interview that was conducted with staff#1, on 08/23/22 during outside lunch time staff#1 observed child#1 was in a way that chair was far from child#1 while child#1 had hands on the table, at that time staff#1 pulled the chair closer to child#1. Per staff#1, never pinched child#1 or any other children at any time.
REPORT CONTINUES ON NEXT PAGE 1 OF 2
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SCHOOL
FACILITY NUMBER: 191203519
VISIT DATE: 11/03/2022
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Per staff#3, staff#1 was placed on administrative leave on 08/24/22. Per staff#3, an interview was conducted with child#1 on 08/23/22 after school hours. Per staff #3, child#1 stated that staff#1 pinched middle back area while they were outside before serving lunch. On 08/23/22, staff#3 checked child#1's back and did not observe any mark.

On 11/03/22 LPA Eivazian watched video footage from 08/23/22 where alleged incident occurred, at the school on director computer. However, the video footage was blurry and not easy to identity children. LPA observed two staff were present on 08/23/22 where alleged incident occurred and director identified as staff#1 and staff#2.

LPA issued the Confidential Names List (LIC 811) to the director during this inspection. The Confidential Names List documents the staff and children involved with the incidents documented in this report.

At this time, there is not a preponderance of evidence that shows that the facility was in violation with Title 22 Regulations when these incident occurred. Therefore, there are no deficiencies being cited.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Director, Lorette Avanessian at 2:30 PM..


END OF REPORT PAGE 2 OF 2
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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