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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494185
Report Date: 09/21/2021
Date Signed: 09/21/2021 05:27:00 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:MIKAYELYAN FAMILY CHILD CAREFACILITY NUMBER:
197494185
ADMINISTRATOR:MIKAYELYAN, SONAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 261-4004
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:14CENSUS: 11DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, Sona MikayelyanTIME COMPLETED:
05:30 PM
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On 9/21/21 Licensing Program Analyst (LPA), Dalicia Adkins conducted an unannounced Annual Required Inspection and was met by Licensee, Sona Mikayelyan . Also present was/were individual #2 and individual #3. Days and hours of operation are Mondays- Fridays 8:30 am-5:30pm.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed, and Licensee confirmed that bathroom and living room are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of locked doors and security gate. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

There are no fireplaces or open face heaters in the home. There is a working fire extinguisher, 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 (818) 261-4004.

There is currently one infant 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.

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SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) -30-3038
LICENSING EVALUATOR NAME: Dalicia AdkinsTELEPHONE: (424) 301-3064
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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: MIKAYELYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494185
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2021
Section Cited

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102370(d)(1) Criminal Record Clearance -(d) All individuals subject to a criminal record review pursuant to ...shall prior to
working...(1)Obtain a California
clearance...This requirment is not met as evidence by:
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Based on observation, record review, and interview license did not ensure that S2 had a criminal background clearance prior to working in the facility, whichposes an immediate healthand safety risk to persons in care
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Type A
09/21/2021
Section Cited

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Clearance -(d) All individuals subject to a criminal record review pursuant to ...shall prior toworking...(1)Obtain a California clearance...This requirment is not met as evidence by:
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Based on observation, record review, and interview license did not ensure that S3 had a criminal background clearance prior to working in the facility, whichposes an immediate healthand safety 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: Karren StarksTELEPHONE: (424) -30-3038
LICENSING EVALUATOR NAME: Dalicia AdkinsTELEPHONE: (424) 301-3064
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021
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: MIKAYELYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494185
VISIT DATE: 09/21/2021
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 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.

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. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on 4/27/2021. Licensee’s pediatric CPR/First Aid expires on 03/20/23. 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 do not have a criminal record clearance or exemption. At 10:50am LPA Adkins confirmed with licensee that individual #2 (S2) and individual #3 (S3) was not fingerprinted. Licensee stated that S2 and S3 assisted her with providing care for children at the facility for one day, 9/21/21. Licensee stated she was not aware of fingerprint clearance requirement for child care homes. Licensee stated that S2 and S3 will not be allowed back at the facility before being fingerprinted. Licensee will submit a written declaration stating knowledge of Title 22 102370(d)(1).

In accordance with California Code of Regulations, Title 22 Child Care Regulation this facility was cited (2) deficiency; this is a violation of Title 22 Child Care Regulation Criminal Record Clearance 102370(d)(1). This violation is a Type A violation, which is an poses an immediate safe and health risk to children in care. A violation regarding no criminal record clearance is an $100 fine for 1 day for S2 and S3 staff. Refer to LIC 809 D

Incidental Medical Services (IMS) not being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.


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SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) -30-3038
LICENSING EVALUATOR NAME: Dalicia AdkinsTELEPHONE: (424) 301-3064
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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: MIKAYELYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494185
VISIT DATE: 09/21/2021
NARRATIVE
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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.

Upon receipt of this report, the Licensee shall post the Notice of Site Visit and any Licensing report documenting a type “A” deficiency. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement of Receipt LIC 9224 form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the Acknowledgement of Receipt of Licensing Reports (LIC 9224).



Exit interview conducted, LPA discussed with licensee new guardian online tool and was provided assistance with accessing online tool to register. A copy of this report and appeal rights provided.

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SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) -30-3038
LICENSING EVALUATOR NAME: Dalicia AdkinsTELEPHONE: (424) 301-3064
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4