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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493676
Report Date: 10/19/2021
Date Signed: 10/19/2021 11:41:55 AM

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:PETROSYAN FAMILY CHILD CAREFACILITY NUMBER:
197493676
ADMINISTRATOR:PETROSYAN, MELINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 645-0199
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:14CENSUS: 15DATE:
10/19/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Meline PetrosyanTIME COMPLETED:
10:44 AM
NARRATIVE
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On 10/19/2021 at 9:10 am, Licensing Program Analyst (LPA) Antonio Almanza and Licensing Program Manger (LPM) Mary Ruiz conducted a Case Management visit at the Licensed Familiy Child Care Home located at 16748 BAHAMA STREET, NORTHRIDGE CA 91343. LPA/LPM met with the Licensee Meline Petrosyan.

Upon Arrival to the Home LPA/LPM observed 15 children and 4 adults in the home. Licensee stated that her infant child was in the home but was supposed to have gone with his dad. At 10:30 am Dad was observed taking the child from the home. 1 of the the four adults in the home does not have a criminal record clearance and was observed supervising children, Licensee states the adult started working in the home today.

Durning todays visit Two Type A deficiencies were cited (see LIC 809Ds) under Title 22 Division 12 Chapter 1. Civil Penalty assessment has been issued on LIC 421 BG.

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 ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC9224) 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.

An exit interview was conducted and a copy of this report, Appeal Rights (LIC9058) along with the Notice of Site Visit were provided to the Licensee Meline Petrosyan.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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: PETROSYAN FAMILY CHILD CARE
FACILITY NUMBER: 197493676
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2021
Section Cited

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102416.5 Staffing Ratio and Capacity (a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This Requirement is not met as evidenced by:
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Based on observation, interview and record review, The Licensee had 15 children in care, which poses an [immediate or potential] Health [and or] Safety, [and or] personal rights risk to persons in care.
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Type A
10/19/2021
Section Cited

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102370 Criminal Record Clearance (d) All individuals subject to a criminal record review pursuant to Health and Safety Code... 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, There were 1 of 5 adults in the home without Criminal Record Clearance which poses an [immediate or potential] Health [and or] Safety, [and or] personal rights risk to persons in 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: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2021
LIC809 (FAS) - (06/04)
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