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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418755
Report Date: 03/08/2023
Date Signed: 03/08/2023 04:40:05 PM


Document Has Been Signed on 03/08/2023 04:40 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:KIUMEHR FAMILY CHILD CAREFACILITY NUMBER:
197418755
ADMINISTRATOR:KIUMEHR, FLORAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 446-0219
CITY:LOS ANGELESSTATE: CAZIP CODE:
90025
CAPACITY:12CENSUS: 7DATE:
03/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Flora KiumehrTIME COMPLETED:
03:15 PM
NARRATIVE
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On 3/8/2023 at approximately 12:40 p.m. Program Analyst (LPA), Judy Laureano conducted an unannounced Annual Required Inspection at 2200 Glendon Avenue, Los Angeles, CA 90025.

Facility operates Monday through Friday 9:00 a.m. to 5:00 p.m. Currently licensee cares for children ages 1 years old to 4 years old and is NOT available for overnight care or weekend care.

LPA toured the home inside and outside and a census was taken; 7 children were present during the inspection with licensee.

The home is a two bedroom, 2 bathroom single family unit with a living room, dining room and guest house. Licensee confirmed the following areas are used for day care: bedroom 2, closet to the main entrance, living room and dining room; these areas are used for napping only. LPA observed a guest house with a kitchen area and bathroom used for day are use. LPA observed children size table, chairs and age appropriate materials. Licensee confirmed the guest house is used for the day care and children nap in the living room, dining room and bedroom 1 of the home. LPA observe the bathroom that children use; located in the guest house. The backyard was observed and inspected. LPA observed age appropriate outdoor toys.

LPA observed a barricaded fireplace. LPA advised licensee to replace the barricade for a stronger gate to ensure children are not able to access the fireplace area.

Licensee confirmed the following areas as OFF LIMITS to the children in care: Kitchen area, bedroom 2 located closest to the kitchen and both bathrooms in the home.

SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
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: KIUMEHR FAMILY CHILD CARE
FACILITY NUMBER: 197418755
VISIT DATE: 03/08/2023
NARRATIVE
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LPA DID NOT observed a working carbon monoxide detector and smoke detector in the home. A working fire extinguisher was observed in the kitchen area and guest house.

There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Sharp object and knives were observed stored in kitchen locked cabinet, made inaccessible to the children 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. Provider physically checks on sleeping infants every fifteen minutes and 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. Infants up to 12 months of age are placed on their backs for sleeping.

Adequate heating and ventilation for safety and comfort were observed in the space. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number 310-869-9975.

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.

Capacity as specified on the license is being maintained during today’s inspection.

SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
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: KIUMEHR FAMILY CHILD CARE
FACILITY NUMBER: 197418755
VISIT DATE: 03/08/2023
NARRATIVE
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LPA reviewed a sample of 5 children’s file and 5 out of 5 files were incomplete. LPA issues 2 Type B citations. LPA discussed the LIC 311D- Records to be maintain in the facility and provided licensee with a current copy to use as a reference when auditing children’s file.

Licensee’s Pediatric CPR and First certification was not valid, expiration date of 1/2020. LPA issues a Type A citation. Licensee agrees to complete an EMSA approved Pediatric CPR and First Aid class by 3/22/2023. Licensee’s Mandated Reporter training was not available for reviewed and a Type B citation was issued. Licensee agrees to complete the Mandated Reporter Training by 3/22/2023.

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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.
Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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 licensee Flora Kiumehr.

SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 03/08/2023 04:40 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: KIUMEHR FAMILY CHILD CARE
FACILITY NUMBER: 197418755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in having 0 (ZERO) carbon monoxide and smoke detectors in the daycare which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2023
Plan of Correction
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Licensee agrees to install a carbon monoxide and smoke detector in the areas designated for day care. Licensee will email a proof of correction to LPA.
Type A
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not having current Pediatric CPR and First Aid certificationn which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2023
Plan of Correction
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Licensee agrees to complete EMSA approved course and submit proof of registration and/or completion of course to LPA via email.
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: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 03/08/2023 04:40 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: KIUMEHR FAMILY CHILD CARE
FACILITY NUMBER: 197418755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current completion of Child Care Mandated Reporter Training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2023
Plan of Correction
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Licensee agrees to complete mandated reporter training and submit proof of completion to LPA via email.
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5] out of 5 children's file did not have proof of immunization, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2023
Plan of Correction
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Licensee agrees to collect proof of immunization of all children enrolled. Licensee will email a copy of documents to LPA. LPA provided the LIC311D for reference.
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: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 03/08/2023 04:40 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: KIUMEHR FAMILY CHILD CARE
FACILITY NUMBER: 197418755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 5 children's file did include LIC 99A, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2023
Plan of Correction
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Licensee will collect signed document from all children enrolled in the program and will email LPA copy of signed LIC99A.

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: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy LaureanoTELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8