197494051-12-14-2021-30-CC-DLOE-C9PU94-20211214142233

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494051
Report Date: 12/14/2021
Date Signed: 12/14/2021 02:22:42 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:	DVALISHVILI FAMILY CHILD CARE		FACILITY NUMBER:	197494051
ADMINISTRATOR:	DVALISHVILI, DALI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 788-1024
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	14	CENSUS: 1	DATE:	12/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Dali Dvalishvili		TIME COMPLETED:	02:35 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 12/14/2021 at 11:50 am Licensing Program Analysts (LPAs), Deborah Lowe and Lisa Clayton conducted an unannounced Annual Required Inspection and was met by Licensee, Dali Dvalishvili. Also present was Staff #1 (S1). Days and hours of operation are Monday – Friday 8:00 am to 6:00 pm.

LPAs toured the home inside and outside and a census was taken. Current facility sketch reviewed and Licensee confirmed that the children’s playroom, bathroom and family room are used for providing care and are accessible to children. The children do have to walk through the living room to access the child care rooms. All other rooms are off-limits and made inaccessible by use of child gate and doors. Swimming pool is fenced per regulation. The pool gate is self-latching, self-closing and opens away from the swimming pool. No windows or doors have direct access to the pool area. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

The fireplace located in the living room is made inaccessible by a child’s safety gate and will not be in use during daycare hours. There is a working fire extinguisher with a service date of 3/25/2021, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. 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 (323) 788-1024.

There are currently no infants in care day of visit. LPA discussed Safe Sleep Regulations with licensee. There is one play yard for each infant in care, play yard was observed to be free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and LPAs reviewed safe sleep documents documenting any signs of distress.

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah Lowe	TELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021

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 4

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: DVALISHVILI FAMILY CHILD CARE	FACILITY NUMBER: 197494051
	VISIT DATE: 12/14/2021

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

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. Currently 1 child under 12 months is enrolled on a drop in basis.

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, no car seats were observed by LPAs. The outdoor play area in the backyard is fenced and there are no hazards to children present. Screen door in play room leading outdoor was observed in need of repair. Capacity as specified on the license is being maintained.

LPAs reviewed 10 children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on 05/01/2020. Licensee’s pediatric CPR/First Aid expires on 09/2022. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

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. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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.htm

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.

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah Lowe	TELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: DVALISHVILI FAMILY CHILD CARE	FACILITY NUMBER: 197494051
	VISIT DATE: 12/14/2021

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 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.

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: (see next page, 809 D) Licensee was provided a copy of appeal rights.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Dali Dvalishvili.

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah Lowe	TELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: DVALISHVILI FAMILY CHILD CARE	FACILITY NUMBER: 197494051
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in screen door in child care room is in need of repair which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/24/2021
	Plan of Correction
1 2 3 4	Licensee will repair or replace screen door in the child care room and will email LPA with pictures showing correction on or before 12/24/2021.

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: Karren Starks	TELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah Lowe	TELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4