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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494202
Report Date: 07/24/2024
Date Signed: 07/24/2024 10:51:14 AM


Document Has Been Signed on 07/24/2024 10:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:PETIKYAN FAMILY CHILD CAREFACILITY NUMBER:
197494202
ADMINISTRATOR:PETIKYAN, LUSINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 919-4159
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:14CENSUS: 6DATE:
07/24/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
07:20 AM
MET WITH:Lusine Petikyan, LicenseeTIME COMPLETED:
10:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Silva Garibyan conducted a site visit for the purpose of a Required- 3 year visit . LPA met with the licensee and toured the home inside and outside at 7:20AM on 07/24/2024. Licensee was present with six children and one assistant. Licensee's home is a single story dwelling with one bedroom, one bathroom, living room with kitchenette. This dwelling is the detached garage that is legally with permits converted in a living space. There is another day care home capacity 14 located in the front of the home with a different address 123331 Lull Street, North Hollywood. CA 91605, license # 197418798. LPA observed the yards separated. The CERTIFICATE OF OCCUPANCY from the City Of Los Angeles posted on the parent board and on file.
Children play, eat and sleep in the living room. There is a pool in the back yard. LPA toured the backyard area to ensure that the pool fencing meets the Title 22 requirements. LPA toured all areas used by children during this inspection. Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption. The bathroom and the kitchenette was observed free of chemicals or toxic items that can pose danger to children in care. The outdoor play area was inspected. Children's outdoor play equipment and toys are age appropriate and in good repair. LPA observed the yard to be fully fenced. The Fire Extinguisher (2A-10-BC) is mounted on the wall in the living room. There is a working smoke/carbon monoxide detectors located in the living room. Page 1
SUPERVISOR'S NAME: Betty BellTELEPHONE: (424) -301-3063
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PETIKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494202
VISIT DATE: 07/24/2024
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LPA observed tables, chairs and napping equipment (14 cots). Licensee reports she has no firearms or weapons in the home. LPA also observed Licensee's and Assistant's current Pediatric CPR (Adult/Infant /Child) and Pediatric First Aid certifications (expire 10/2025) and Licensee's and Assistant's Mandated Reporter Training Certifications(completed 02/08/2024).
The bathroom and the kitchen was observed free of chemicals or toxic items that can pose danger to children in care. Children play in the front yard. LPA observed the yard to be clean, free of debris, and fully fenced. The fire drills are done twice a year. Last drill was conducted on 6/13/2024. Licensees provide meals and snacks. LPA discuss food preparation, storage and ensuring a log and information regarding dietary restrictions and allergies are kept up to date. Licensees stated that a cell phone with active service in the home will be the main contact number while children are in care.
LPA observed in the play room the Parent Board with all necessary posting required ( Facility License (LIC 203), Emergency Disaster Plan (LIC610A), Notification of Parents' Rights Poster (PUB 394), If You see Something Say Something poster, Car Seat Safety poster). Child Care Facility Roster (LIC9040) was on file.

A review of the children's records was conducted and are found to have the following: LIC 282 Affidavit Liability Insurance, LIC 627/Consent for Medical Treatment, LIC 700/ID and Emergency Information, LIC702, LIC 995A/Parent's Rights, LIC995E/Caregiver Background Check, LIC 9150/Parent Notification, LIC 9212/Parent's Responsibilities, PM 286/Immunization Card.

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SUPERVISOR'S NAME: Betty BellTELEPHONE: (424) -301-3063
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PETIKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494202
VISIT DATE: 07/24/2024
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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.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.



Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
No infants are enrolled at this time. LPA discussed the safe sleep regulations with licensees 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.

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SUPERVISOR'S NAME: Betty BellTELEPHONE: (424) -301-3063
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PETIKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494202
VISIT DATE: 07/24/2024
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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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensees were informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the licensee Lusine Petikyan confirmed that there are no Registered Sex Offenders living in the facility.

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

Exit interview conducted and report was reviewed with the licensee Lusine Petikyan.

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SUPERVISOR'S NAME: Betty BellTELEPHONE: (424) -301-3063
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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