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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197417251
Report Date: 03/07/2022
Date Signed: 03/07/2022 10:40:37 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
08/26/2021 and conducted by Evaluator Silva Garibyan
PUBLIC
COMPLAINT CONTROL NUMBER: 30-CC-20210826110431
FACILITY NAME:AGAYBY FAMILY CHILD CAREFACILITY NUMBER:
197417251
ADMINISTRATOR:AGAYBY, GERMINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 237-5768
CITY:ENCINOSTATE: CAZIP CODE:
91316
CAPACITY:12CENSUS: 9DATE:
03/07/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Germin Agayby/LicenseeTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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1) Personal Rights: Daycare child has a healing fracture that is suspected to have happened at the daycare.
2)Personal Rights: Daycare child received injuries while in care.
3) Reporting Requirements: Provider did not report serious injury to authorized representative in a timely manner.
4) Personal Rights: Infant sleeps on a mat on the floor.
INVESTIGATION FINDINGS:
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On 03/7/2022 at 10:00 a.m., Silva Garibyan, Licensing Program Analyst (LPA), conducted an unannounced site visit for the purpose of delivering findings for complaint received on 08/26/2021. LPA met with Germin Agayby, Licensee, and explained the reason for the visit.

This investigation was conducted by the Department's Investigator Robert Kujawa.
LPA Garibyan met with Germin Agayby , Licensee, and toured the facility with her on March 07, 2022. There were 9 children (including 4 infants) and one assistant present at the time of the visit. Based upon the evidence obtained through the course of investigation there is insufficient evidence to support or disprove the above allegations. Therefore, these allegations have been determined unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
A copy of this Report, Appeal Rights, and Notice of Site Visit were explained and provided to the Licensee, Germin Agayby.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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