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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197402457
Report Date: 04/14/2020
Date Signed: 04/14/2020 01:58:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:GEVONDYAN FAMILY CHILD CAREFACILITY NUMBER:
197402457
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 8DATE:
04/14/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Maryna Gevondyan TIME COMPLETED:
01:25 PM
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On 4/14/2020 at 10:00AM Licensing Program Analyst (LPA) Jeanette Estrada conducted an announced Pre-Licensing Tele-Inspection via Facetime at the Gevondyan Family Child Care Home. LPA met with the Licensee, Maryna Gevondyan who guided LPA on a tour of the facility. This pre-licensing inspection is being conducted as a tele-visit via Facetime due to the Covid-19 Crisis and the Safer at Home Mandate. Per Licensee, family members residing in the home are 2 adults and 2 children. Present during the tele-inspection were the Licensee and her assistant, Asroshnoik Matinyan, who is associated to the facility. The census during today’s visit was 8 (1 infant). Licensee is requesting a large family child care home license. Per Licensee, operating hours will be Monday to Friday, 7:30 AM to 6:00 PM. Licensee states that she will care for children 0-10 years of age.

The Gevondyan FCCH is a two-story home which consists of 5 total bedrooms. The 1st floor consists of 1 bathroom, 1 bedroom, a living room, a dining room, a kitchen and a family room. At the time of the inspection the facility sketch did not indicate the off-limit areas. Per the Licensee, the off-limit areas in the 1st story of the home are the kitchen, family room and the attached garage. The 2nd story consists of 4 bedrooms and 2 bathrooms and it is completely off limits. LPA observed the stairs to the 2nd story barricaded by a gate.

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SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3023
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (424) 301-3023
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GEVONDYAN FAMILY CHILD CARE
FACILITY NUMBER: 197402457
VISIT DATE: 04/14/2020
NARRATIVE
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Per the Licensee, the children will use the restroom in the 1st floor, the bedroom used as the crib room, living room used as the main day care room, dining area and the backyard. Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone and land line), ventilation and heating (central and inaccessible to children. Children nap in the main day care room (living room on Facility Sketch) and they are provided with a cot and bedding. Per the Licensee, she provides the bedding and the families take them home once a week to be cleaned. The main day care room is furnished with age appropriate furniture and toys. Per the Licensee, currently only two children nap in the crib room. In the crib room LPA observed 5 cribs, a changing table and diapering supplies. The children eat in the dining room and they are provided meals. LPA observed a water pitcher and plastic cups readily available. Detergents, cleaning compounds and hazardous items that can pose a danger to children are inaccessible and are kept in a latched cabinet under the kitchen sink. LPA observed the knives locked in an upper cabinet in the kitchen where they are inaccessible to children in care. In the bathroom used for the day care, LPA observed latched cabinets.

LPA observed 3 smoke detectors in the following rooms; crib room, dining room and day care room. Smoke detectors were tested and are in working condition. LPA observed a carbon monoxide detector placed in a hallway in between the kitchen and dining room which was tested and is in working condition. There is a first aid kit located in the kitchen CLOSET. LPA observed a 2A10BC Fire Extinguisher in the pantry which per the Licensee was serviced in summer 2019. Per the Licensee there are no weapons or fire arms in the home. There are no pets in the home. If needed, the family room is used as the isolation room. Per the Licensee, fire drills are conducted once a month. The Licensee has completed the required Health and Safety Training, Nutrition Training and Pediatric First Aid and CPR which expires 01/2022. LPA observed the required postings; Facility License, LIC 610 Emergency Disaster Plan, LIC 9148 Earthquake Preparedness Checklist, PUB 394 Notification of Parents Rights.

Continued on PG.3
SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3023
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (424) 301-3023
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2020
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GEVONDYAN FAMILY CHILD CARE
FACILITY NUMBER: 197402457
VISIT DATE: 04/14/2020
NARRATIVE
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PG.3
The outdoor area was observed to be free from defects or conditions which might endanger children in care. Per the Licensee the entire outdoor area is accessible to children in care. Children are directly supervised by the Licensee or the Assistant when children are using the outdoor area.

Corrections to be made:
Licensee is to submit the LIC 995- FACILITY SKETCH indicating the OFF-LIMIT AREAS as discussed during the tele-inspection.

*Tele-inspection ended at 10:45AM. LPA contacted Licensee via Facetime to conclude the exit interview at 1:00PM.
The following was discussed with the Licensee:
Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance.
 In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR training, Immunizations (TDAP, MMR, Influenza), mandated reporter training and a valid criminal record clearance associated to the facility license.
 The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked and batteries replaced as needed.
 Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
 Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing using form LIC 624B.

Continued on PG.4

SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3023
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (424) 301-3023
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2020
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GEVONDYAN FAMILY CHILD CARE
FACILITY NUMBER: 197402457
VISIT DATE: 04/14/2020
NARRATIVE
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PG. 4
Fire and safety drills must be performed every six months and documented for review by the Department.
 Smoking is prohibited in a family child care home.
 Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility. Never sleep an infant in a car seat.
Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
 The facility license number must be on all advertisements, publications or announcements with the intent to attract clients.
 Isolation for ill children: When a child is ill he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).
Immunization Requirement: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The licensee and all adults working with children have proof of immunizations.

Mandated Reporter Training: H&S 1596.8662: Beginning January 1, 2018, all licensed providers, applicants, directors and employees to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com

Continued on PG. 5

SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3023
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (424) 301-3023
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2020
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GEVONDYAN FAMILY CHILD CARE
FACILITY NUMBER: 197402457
VISIT DATE: 04/14/2020
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PG. 5
Infant Care: Licensee states that she is currently caring for one infant. LPA advised the Licensee to sleep infants where they can be directly supervised. The applicant states the following as a supervision plan for infants: Licensee states that infants sleep in the crib room where she will be providing supervision. Additional information for the Safe to Sleep campaign can be found on: https://safetosleep.nichd.nih.gov/

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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)/ (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 advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov. LPA reviewed the Forms/Records to Keep in Your Family Child Care Home (LIC 311D):

CHILDREN FORMS/RECORDS - Children’s files must contain the following documents/information:
Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), Family Child Care Consumer Awareness Information (LIC 9212), Consent/Verification for Nebulizer Care (LIC 9166), California School Immunization Record, Parent Notification for Additional Children in Care (LIC 9150), Affidavit Regarding Liability Insurance (LIC 282), Acknowledgment of Receipt of Licensing Reports (LIC 9224).

Continued on PG. 6
SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3023
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (424) 301-3023
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2020
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GEVONDYAN FAMILY CHILD CARE
FACILITY NUMBER: 197402457
VISIT DATE: 04/14/2020
NARRATIVE
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PG. 6
FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records: As required in Title 22 Regulations 102416.1, Unusual incident/Injury Report (LIC 624B): Child Care Facility Roster (LIC 9040), Notice of Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108), Property Owner/Landlord Consent (LIC 9149), Property Owner/Landlord Notification Form (LIC 9149).
INFORMATION TO BE POSTED IN YOU FAMILY CHILD CARE HOME – You are required by Law to post the following:
Facility License (LIC 203), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Notification of Parent’s Rights (PUB 394). A Notice of Site Visit (LIC 9213): Must be posted for 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

An exit interview was conducted with the Licensee via telephone at 1:09PM. A copy of this report and the Notice of Site Visit will be sent to the Licensee via EMAIL. The Licensee agrees to reply to the email stating the report was received and read as verification.

SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3023
LICENSING EVALUATOR NAME: Jeanette EstradaTELEPHONE: (424) 301-3023
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2020
LIC809 (FAS) - (06/04)
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