197418513-6-23-2022-30-CC-SORS-CFNUWT-20220623155717

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197418513
Report Date: 06/23/2022
Date Signed: 06/23/2022 03:57:28 PM

Document Has Been Signed on 06/23/2022 03:57 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	KAZARJANA FAMILY CHILD CARE		FACILITY NUMBER:	197418513
ADMINISTRATOR:	KAZARJANA, LIANUSA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 268-5872
CITY:	ENCINO	STATE: CA	ZIP CODE:	91316
CAPACITY:	14	CENSUS: 9	DATE:	06/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:17 PM
MET WITH:	KAZARJANA, LIANUSA -Licensee		TIME COMPLETED:	04:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/23/2022 Licensing Program Analyst (LPA), Suzette Ornelas conducted an unannounced Annual Required Inspection and was met by Licensee, KAZARJANA, LIANUSA. Also present was Staff #1 (S1). Days and hours of operation are Monday through Friday 8a to 6p. LPA toured the home inside and outside and a census was taken, LPA observed 9 children. Current facility sketch reviewed and Licensee confirmed that the living room, bedrooms 1&2, and bathroom located in the hallway are used for providing care and are accessible to children. The kitchen is used only to lead the children to the backyard area. All other rooms are off-limits and made inaccessible by use of closed doors, safety gate and supervision. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. LPA did not observe any poisons during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible by being stored in a high cabinet or by a closed door. There are no fireplaces or open face heaters in the home. LPA observed a working fire extinguisher at least 2A10BC serviced on June 2022. Smoke detector and carbon monoxide detector located in the living room and hallway of the home were observed to be in working conditions. Adequate heating and ventilation for safety and comfort and all electrical outlets were covered with plastic covers. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (818)268-5872. There is currently 1 infant in care. LPA discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette Ornelas	TELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

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 6

Document Has Been Signed on 06/23/2022 03:57 PM - It Cannot Be Edited

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: KAZARJANA FAMILY CHILD CARE	FACILITY NUMBER: 197418513
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 infants did not have an infant sleep log on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2022
	Plan of Correction
1 2 3 4	Licensee/assistant immediately began documentation of sleeping infant.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette Ornelas	TELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

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: KAZARJANA FAMILY CHILD CARE	FACILITY NUMBER: 197418513
	VISIT DATE: 06/23/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Provider physically checks on sleeping infants every fifteen minutes; however, does not documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping. LPA did not observe an infant sleep log for 1 infant in care. LPA observed the assistant in the same room where the children were sleeping the entire time. LPA provided licensee with a copy of the infant safe sleep regulation, explained and provided a sample of an infant safe sleep log. Licensee/assistant immediately began documentation of sleeping infant.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. LPA observed files to be missing the PM 286 in the children’s files; however, provider has all the immunization records for all the children in care. LPA provided a copy of the PM 286 and instructions on the requirement to complete and maintain the form in addition to the children’s immunization records in each file. Licensee’s Mandated Reporter Training was completed on 11/29/2021. Licensee’s pediatric CPR/First Aid expires on 07/2023. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles. LPA did not observe a current mandated reporter training certificate for assistant. LPA provided a copy of the 1596.8662 HSC and explained to licensee the regulation and requirement for all adults employed to have a current Mandated Reporter Training Certificate renewed every 2 years.

All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home. Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette Ornelas	TELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

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: KAZARJANA FAMILY CHILD CARE	FACILITY NUMBER: 197418513
	VISIT DATE: 06/23/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited: Type B: 102425(j)(2)(D) – Infant Safe Sleep (see next page, 809 D)
Licensee was provided a copy of appeal rights.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette Ornelas	TELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

LIC809 (FAS) - (06/04)

Page: 6 of 6