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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419778
Report Date: 04/05/2022
Date Signed: 04/05/2022 12:28:17 PM


Document Has Been Signed on 04/05/2022 12:28 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:AGSHEHIRLYAN FAMILY CHILD CAREFACILITY NUMBER:
197419778
ADMINISTRATOR:KARINE AGSHEHIRLYANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 448-6767
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91601
CAPACITY:14CENSUS: DATE:
04/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Licensee: KARINE AGSHEHIRLYANTIME COMPLETED:
12:45 PM
NARRATIVE
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On 4/5/22 at 9:51 a.m., Licensing Program Analysts (LPA) Antonio Almanza were at the licensed facility conducting an alternate inspection when the deficiencies listed below were observed. LPA observed 9 children in care and two adults providing care and supervision to children in care, Licensee arrived after LPA at approximately 10:15 a.m.

Deficiencies observed:
At 10:09 AM licensee's assistant (Staff #1) was observed by LPA providing care to day care children without a criminal record clearance. After obtaining statements from facility staff members and licensee, it was determined that Staff #1 has been in the facility for about 1 month. This will result in a Type A citation, see LIC809-D. A civil penalty will also be issued, see LIC421BG

At 10:19 AM LPA observed 6 bottles of cleaning supplies under the bathroom sink. Lpa also observed Care products in two of the three drawers under the bathroom sink. This will result in a Type A citation, see LIC809-D.

At 10:57 AM LPA observed a child entering the kitchen from the living room and the Licensee redirected the child out of the kitchen. At 10:58 AM LPA observed a butcher block with knifes on the kitchen counter. The door that leads to the living room area was wide open and does not have any child safety latch or lock that will make it inaccessible to children. The door that leads out to the yard was also wide open without any child safety gates.

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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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 3


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: AGSHEHIRLYAN FAMILY CHILD CARE
FACILITY NUMBER: 197419778
VISIT DATE: 04/05/2022
NARRATIVE
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Two Type A deficiencies were cited during today's inspection (see LIC 809Ds). Each report (documenting a Type A citation) shall remain posted for 30 days along with the Notice of Site Visit (printed out during this inspection).

**In addition; A copy of this report must be provided to the authorized representatives of all currently enrolled children and any newly enrolled child for the following 12 months.
The LIC9224 ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (was provided to the licensee) shall be signed and kept in each of the children’s records. The report shall be provided no later than the next business day or the next day the child is in care.

A copy of this report, notice of site visit, Appeal Rights (LIC 9058), were given and explained during this inspection.

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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/05/2022 12:28 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: AGSHEHIRLYAN FAMILY CHILD CARE
FACILITY NUMBER: 197419778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2022
Section Cited

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102370(d)(1) Criminal Record Clearance(d) All individuals subject to a criminal record review... shall prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.
This Requirement is not met as evidenced by:
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Based on observation, interview and record review, The Licensee did not make sure that Staff 1 has a criminal record clearance prior to working or volunteering in Licensed facility, which poses an immediate Health and Safety, and personal rights risk to persons in care.
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Type A
04/05/2022
Section Cited

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102417(g)(4) Operation of a Family Child Care Home: Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.
This Requirement is not met as evidenced by:
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Based on observation, The Licensee did not make Poisons, detergents, cleaning compounds inaccessible to children under the bathroon sink. LPA observed nifes on kitchen counter and 2 doors to kitchen open, which poses an immediate Health and Safety, and personal rights risk to persons in care.
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Licensee has removed nifes from kitchen counter and placed them on top kitchen cabinet.
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: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
LIC809 (FAS) - (06/04)
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