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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493534
Report Date: 12/04/2019
Date Signed: 12/04/2019 02:03:12 PM

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:TAVKHELIDZE FAMILY CHILD CAREFACILITY NUMBER:
197493534
ADMINISTRATOR:TAVKHELIDZE, AMRINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 660-3200
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:14CENSUS: DATE:
12/04/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Amrin TavkhelidzeTIME COMPLETED:
02:15 PM
NARRATIVE
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On 12/4/2019 at approximately 11:30 am, Licensing Program Analyst, Stella Gutierrez met with Licensee, Amrin Tavkhelidze and explained the purpose of todays visit of an annual random inspection to ensure that facility is in compliance with Title 22 regulations and Health and Health Safety codes. Upon arrival, LPA observed 6 children ( 2 INFANTS and 4 Pre-Schoolers) being supervised by licensee and assistant Jaswinder Kaur. Facility is licensed for a capacity of 14 children. Facility is operating within capacity limitations. All adults observed during today’s visit are fingerprinted and associated to the facility. Licensee guided LPA on a tour of the facility inside and out. Hours of operation are from 7:00 AM - 7:00 PM Monday through Friday.

Areas identified in the sketch and observed by LPA, Gutierrez during todays visit:

Interior:
This is a single-story dwelling, two-bedroom, two- bathroom home with kitchen/dining, living room, detached garage and guest home located behind the home. When LPA, Gutierrez arrived to the facility, Licensee greeted LPA at front door of main home. Licensee directed LPA to go through side gate (right of home) to get to back of guest home where the child care is provided. Back Guest house is Licensee’s residence and Licensee’s Mothers home is the main home. The Child care is only provided at the back guest at which is the Licensee’s residence and place she and husband live. Bedroom is located adjacent to main play room in guest house and is inaccessible to the children Family members residing in the home include licensee and spouse. All furniture was found in good repair, clean, and without hazards. Children utilize the bathroom located adjacent to main play room. The Bathroom is with locks and free from hazards. The kitchen is the main house and inaccessible to children in care. The home has a no fireplace. A wall heater was observed today (not in use) Licensee stated that she will use the heater in the future. There were tables and

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SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019
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: TAVKHELIDZE FAMILY CHILD CARE
FACILITY NUMBER: 197493534
VISIT DATE: 12/04/2019
NARRATIVE
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craft items in front of heater. LPA, Gutierrez observed the interior for age appropriate toys, learning materials, games and activities for children in care., The facility was inspected inside and outside for safety, comfort, cleanliness, telephone service heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds , and hazardous items (sharp knives in kitchen only) that can pose a danger to children. There are no fire arms kept on the premises. LPA observed a working smoke detector, operable carbon monoxide detector and 2A10-BC fire extinguisher (serviced in 2015)


Inspection of the outdoor play area was conducted:

Main play yard has a space for children to do arts and crafts, bike ride and running zone. Fencing around the perimeter of the back yard. Per facility sketch there is no pool, spa or other bodies of water on the premises. LPA observed a small hot tub half full of water in main play running zone) yard today. Swing set, trampoline and slide was observed outside in main play yard. BBQ , Licensee stated that it is never in use.

Administration:

LPA reviewed the following items during today’s visit:

Children’s Roster, 6 children’s files, Licensee’s required documents including, Pediatric First Aid and Adult, Child and Infant CPR to be current (expires on 06/2020) and preventative heath and safety certification and fire drill log.

LPA discussed capacity limitations, new car seat law, personal rights, Notification of Parent's Rights revised 12/06, inspection authority & agency's consultative role. Smoking is prohibited on the premises when children are present. The LPA also discussed earthquake safety and necessity of drills every 6 months. The applicant was also informed that all adults living in or having access to day care children in the home are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Index prior to having contact with children. If the aforementioned is not adhered to, a Civil Penalty of $100 /day per uncleared adult will be assessed.

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SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019
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: TAVKHELIDZE FAMILY CHILD CARE
FACILITY NUMBER: 197493534
VISIT DATE: 12/04/2019
NARRATIVE
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The facility is not currently providing IMS. Incidental Medical Services (IMS) policy was discussed with the Licensee. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. LPA obtained a copy of the facility's IMS Plan. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.html

The licensee was informed of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on child care licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541.


Email Address: childcareadvocatesprogram@dss.ca.gov

Safe Sleep Links:
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx


NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

SIDS & SHAKEN BABY SYNDROME INFORMATION (discussed) flyer provided.


LPA provided safe sleep flyer and discussed safe sleep practice. Infants must be placed on their backs and must be physically checked every 15 minutes to gauge temperature and ensure they are breathing. Licensee, Amrin Tavkhlidze stated that she understands safe sleep practice for infants and to ensure supervision at all times infant’s are in care at TAVKHELIDZE FAMILY CHILD CARE facility.

FORMS TO BE POSTED AND OBSERVED BY LPA during today’s visit


· LIC203 Facility License
· LIC 610A Emergency Disaster Plan
· LIC 9148 Earthquake Preparedness Checklist
· PUB394 Notification of Parents Rights Poster

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SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019
LIC809 (FAS) - (06/04)
Page: 3 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: TAVKHELIDZE FAMILY CHILD CARE
FACILITY NUMBER: 197493534
VISIT DATE: 12/04/2019
NARRATIVE
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Senate Bill 792: This bill, commencing September 1, 2016, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles.

New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment. A copy provider rights and Appeal process provided to Licensee. All appeals must be sent to:

California Department of Social Services | Community Care Licensing Division
300 Continental Blvd., Suite 290-A
El Segundo, CA 90245

New Immunization Requirement: Law enacted by SB 277, beginning January 1, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into child care or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint.

Assembly Bill 1207: California Child Care Workers; Mandated Training Requirement. Beginning January 1, 2018, all licensed providers, applicants, directors and employees must complete Mandated Reported Training prior to March 30, 2018 and renew training every two years at: www.mandatedreporterca.com. Volunteers are encouraged but not required to take the training. Providers are to complete the 4 hour General Training and 3 hour Child Care Provider Training. Please keep these two certificates in employee files for Licensing Program Analyst review. Licensee could not provide proof of Mandated Training during today's visit.

Nutrition Requirement: Beginning January 1, 2016, AB 290 will require for each new license issued, at least one director or teacher at each child care center or family child care home to have at least one hour of training in the importance of childhood nutrition. This applies to anyone submitting a new application, relocating their facility, selling their facility or transferring their license. Please note this training cannot be completed online or by home study programs. The training must be taken from an Emergency Medical Services Authority (EMSA) approved training program OR an accredited college or university.

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SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019
LIC809 (FAS) - (06/04)
Page: 4 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: TAVKHELIDZE FAMILY CHILD CARE
FACILITY NUMBER: 197493534
VISIT DATE: 12/04/2019
NARRATIVE
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Assembly Bill 633: Upon receipt by the licensee, licensees are to provide to parents/guardians the following: Copies of any licensing reports that document a Type A citation- this includes facility visits and substantiated complaint investigations; copy of licensing documents pertaining to a conference conducted by a local licensing agency management representative and the licensee of this family child care home in which issues of noncompliance are discussed or copies of a summary of an accusation indicating the Department's intent to revoke the facility's license. Copies of any of the above licensing documents the licensee has received in the prior 12 months shall be provided to parents/guardians of newly enrolled child at the facility.

The following was discussed thoroughly as a Proof of Correction due to LPA, Gutierrez by 12/11/2019 AT before 5:00 PM. Card provided to licensee to send updates to email and a continued case management visit may be conducted.

1. Mandated training Certification for all employees present during today's inspection. This includes a total of 7 hours (3 hours general training and 4 hours child care provider training) Flyer given for more information about www.mandatedreporterca.com
2. Hot tub in main play area that is accessible to the children can pose and immediate danger to the children in care. Please provide a picture of the hot tub removed from play area. Licensee was informed that children cannot play in main play are until the tub is removed and the gate shall be kept shut at all times. Written Declaration received.
3. A copy of signed copies of LIC 9224 forms to all parents of children currently enrolled in the facility (x6)

The facility was found to be NOT in compliance per Title 22 regulations, The facility will be cited a Type A and a Type B violation today.

An exit interview was conducted and copy of this report, appeal rights and cite visit was provided.
The licensee was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. Copies of the reports must also be provided to each parent when a serious deficiency, Type A, is cited (LIC9224).
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SUPERVISOR'S NAME: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019
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: TAVKHELIDZE FAMILY CHILD CARE
FACILITY NUMBER: 197493534
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/11/2019
Section Cited

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102417(g) (5) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to:
5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds
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and similar bodies of water through a pool cover or by surrounding the pool with a fence.

Based on today's inspection of the facility this requirement was not met. LPA, Gutierrez observed a hot tub half full of water in main play area making it inaccessible and pose an immediate danger to children in care.
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Type B
12/11/2019
Section Cited

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(3) On and after January 1, 2018, a person who becomes an administrator or employee of a licensed child day care facility shall complete the mandated reporter training ...

Based on todays observations this requirement was not met by Licensee or any of the other staff providing 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: Victor BautistaTELEPHONE: (424) 301-3008
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (424) 301-3065
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2019
LIC809 (FAS) - (06/04)
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