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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197412218
Report Date: 05/30/2019
Date Signed: 05/30/2019 11:21:46 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/24/2019 and conducted by Evaluator Marina Pilossian
PUBLIC
COMPLAINT CONTROL NUMBER: 30-CC-20190524163459
FACILITY NAME:DANIELIAN & POGOSOV FAMILY CHILD CAREFACILITY NUMBER:
197412218
ADMINISTRATOR:DANIELIAN, IRINA S.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 892-2275
CITY:NORTHRIDGESTATE: CAZIP CODE:
91343
CAPACITY:14CENSUS: 6DATE:
05/30/2019
UNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Irina DanielianTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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1) Personal Rights:Child sustained an unexplained injury while in care.
2) Reporting Requirements: Licensee failed to inform the child's authorized representative of his injury.
3) Reporting Requirements: Licensee failed to report the incident to the Department of Social Services/CCL.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA), Marina Pilossian met with licensee Irina Danielian regarding the above allegations. LPA toured the facility with the licensees at 7:35am on 05/30/2019. LPA observed both licensees present with no day care children. After some time, LPA observed assistant arrive at the facility. After sometime, six day care children dropped off at the day care. Licensee is Armenian Speaking. LPA conducted the visit in Armenian.
Licensee admitted to LPA during the interview that child #1 was dropped off in the morning with no injuries, then around 11:30am, child #1 fell from a small/medium size brown play horse on the white marble tile in the activity room causing a bruise to the childs forehead. Licensee admitted to LPA Pilossian that she did not call Licensing and did not call the mother to inform her of the injury.

LPA reviewed child's file. Based on the information obtained from the interviews conducted and observations by the LPA, the above allegations of Personal Rights, and reporting requirements are substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The Licensee will be cited according to Title 22 Regulations. Please see Complaint Investigation Report LIC 9099C for additional information.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 30-CC-20190524163459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: DANIELIAN & POGOSOV FAMILY CHILD CARE
FACILITY NUMBER: 197412218
VISIT DATE: 05/30/2019
NARRATIVE
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See LIC 9099D. The Notice of Site Visit, and this report must be posted for 30 days and copies must be provided to all parents and to parents enrolling for the next 12 months. LIC 9224 must be signed as proof.

The facility was cited Type A deficiency for Personal Rights, and Type B deficiencies for Reporting requirements in accordance with The California Code of Regulations, Title 22, Division 12, and Chapter 3.

See LIC 809-D for deficiencies cited.

LPA read this report for the licensee and explained to her in detail. Licensee is Armenian speaking.


SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2019
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 30-CC-20190524163459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: DANIELIAN & POGOSOV FAMILY CHILD CARE
FACILITY NUMBER: 197412218
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/30/2019
Section Cited
CCR
102423(a)(2)
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Personal Rights. Each child shall be accorded safe, healthful and comfortable accommodations, furnishing and equipment.
This requirement is not met as evidenced by: Licensee admitted to LPA Pilossian during the interview, that child #1 fell from small/medium size play horse on to marble
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Effective immediately, licensee shall ensure that the personal rights of children in care are protected at all times to prevent this type of incidents from re-occurring. Licensee shall submit a written statement to the Department no later than 5/30/19 indicating how she is going to ensure the personal rights of children in care will not be violated.

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tile floor in the activity room, causing injury (bruise) to the fore head. Licensee failed to provide a safe environment.

This is a type A deficiency as it poses immediate danger to the health and safety of children in care.
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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: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2019
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 30-CC-20190524163459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: DANIELIAN & POGOSOV FAMILY CHILD CARE
FACILITY NUMBER: 197412218
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2019
Section Cited
CCR
102416.2(f)(1)
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Reporting Requirements. Licensee failed to contact child's emergency contact. Per Title 22 Regulations, as soon as possible, any injury suffered by a child in care shall be reported to that child's parent or authorized representative regardless of treatment by a medical professional.
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The licensee shall provide a written declaration outlining her understanding that any injured child's parent or authorized representative must be notified as soon as possible regardless of treatment by a medical professional and submit it to the Department no later than 6/6/19. by fax or mail.
Type B
06/06/2019
Section Cited
CCR
102416.2(d)
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Reporting Requirements. A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home of…the…events." This requirement is not met as evidenced by: Licensee failed to inform the Department that
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The licensee is required to provide a written Declaration that she has read and understands the Departments reporting requirements, and shall submit an incident report no later than6/6/19 documenting the incident that occurred at the facility on 5/23/19 either by mailing the Unusual Incident Report form (LIC624B) or by faxing
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on 05/23/2019 at approximately 11:30am., child #1 sustained injury (bruise) to the forehead, and licensee fail to notify the Department within 24 hrs. and failed to submit a written report. This is a Type B deficiency which poses a potential Health and Safety risk to children in care.
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to the office at:
EL SEGUNDO CHILD CARE RO
300 CONTINENTAL BLVD., SUITE 290A
EL SEGUNDO CA 90245
FAX # 424 301-3200 ATTN: LPA Pilossian
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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: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Marina PilossianTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2019
LIC9099 (FAS) - (06/04)
Page: 4 of 4