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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494501
Report Date: 02/26/2020
Date Signed: 03/02/2020 09:43:44 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:GOZEN FAMILY CHILD CAREFACILITY NUMBER:
197494501
ADMINISTRATOR:NATALIE GOZENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 358-5980
CITY:VA;;EY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:14CENSUS: 0DATE:
02/26/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
07:15 AM
MET WITH:Natalie Gozen/LicenseeTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA), Silva Garibyan met with the applicant, Natalie Gozen, for the purpose of a Change of Location Pre-Licensing visit. Applicant has applied for a large capacity (14) family child care home license. The applicant has an approved fire clearance ( Fire Clearance granted by inspector Shawn Connolly on 02/18/2020). Applicant has no pets. LPA toured the facility with the applicants on 02/26/20 at 7:25 AM. Applicants' home is a two story, 3 bedroom, 3 bathroom home with living/dining room, step down family room, kitchen, and attached garage ( accessible for the family room, door knobs are placed ). The main entry door will be used to enter the facility. Entire second floor (including three bedrooms, two bathrooms), the kitchen, and the attached garage are off limits to the children in care. Safety gate is installed by the stairs to make the second floor inaccessible. Safety gate is installed to make the kitchen inaccessible. The garage has not been fully converted and applicant is fully aware that children may not eat or sleep in the garage. Children will eat and sleep in the living/dining room. The children will have access to the bathroom ( 4 steps down) located on the first floor. Applicant was reminded that children must be escorted when using the stairs. Family members residing in the home include two adults ( licensee and her husband) and two children ( 8 and 4 years old). 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 observed the pool fencing to be 5 feet high, have a self latching gate that swings away from the pool and has a self latching device that is located no more than 6 inches from the top of the fence. The mesh fence encloses the pool on one side. The back and sides are enclosed by the property wall. The mesh fencing is sturdy and capable of withstanding the impact of children's toys including bicycles. There are no other bodies of water on the premises. LPA took photos to document in the file. The pool fence meets Title 22 regulations., Applicants have submitted a disaster plan and demonstrated control of property at the above address by presenting Property Tax Bill. Page 1 of 5
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2020
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 5
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: GOZEN FAMILY CHILD CARE
FACILITY NUMBER: 197494501
VISIT DATE: 02/26/2020
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The applicants have completed preventive health and safety/Childhood Nutrition and Mandated Reporter training ( completed on 07/16/2019). There are age appropriate toys and equipment for the children.

The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Applicant states there are no firearms or weapons of any kind in the facility at this time. The First Aid kit was observed and complete. The required fire extinguisher (2A 10BC) and smoke/carbon monoxide detectors are in operable condition. The applicant has current pediatric CPR/First Aid training that will expire in June of 2021. LPA Garibyan toured the outdoor area. Children will utilize the back yard area to play. The back yard is fully fenced.

Applicant was informed that it is required by law to post the following in the facility:

● Emergency Disaster Plan (LIC 610A) - This must be posted in your home next to the telephone and


the Earthquake Preparedness Checklist (LIC 9148), must be attached to the LIC 610A and available
to the public.
● Notification of Parents' Rights Poster (PUB 394) - This poster must be placed in an area of the home
where all parents can see it
● Facility License, (LIC 203)-Your Family Child Care Home License must be posted in an area of the
home where it can be easily seen.
● Notice of Site Visit (LIC 9213) must remain posted for 30 days (during the hours that children are in
care) after each site visit by a licensing representative.
● Any licensing report documenting a type “A” citation must be posted for 30 days during the hours that children are in care.
● Any licensing report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.
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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2020
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: GOZEN FAMILY CHILD CARE
FACILITY NUMBER: 197494501
VISIT DATE: 02/26/2020
NARRATIVE
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Mandatory Forms for the children’s files: (LIC 282 Affidavit Liability Insurance, LIC 627/Consent for Medical Treatment, LIC 700/ID and Emergency Information, LIC 995A/Parent's Rights, LIC995E/Caregiver Background Check, LIC 9150/Parent Notification, LIC 9212/Parent's Responsibilities, PM 286/Immunization (Blue) Card).

Employee records must be maintained by the applicant and shall contain the following: LIC9052/Employee Rights, LIC 9108 Mandated Reporter Form, An employment contract or application containing the following information: Employees Full Name, Date of Birth, Driver's License Number, Date of Employment, Documentation of Health and Safety Training, Duties of the employee. Licensee is reminded that records for employees as well as children must be maintained for 3 years after separation for the FCCH.


Requirements for fire drills, earthquake drills, and documentation for both. Role and responsibilities of being a mandated reporter were reviewed. The applicant was advised how to access forms and Regulations for Family Child Care online at www.ccld.ca.gov. Regulation prohibits the smoking of tobacco in a private residence licensed as a family child care home during the hours of operation. State law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category.

The following was thoroughly discussed with the licensee:



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.

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. page 3 of 5
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2020
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: GOZEN FAMILY CHILD CARE
FACILITY NUMBER: 197494501
VISIT DATE: 02/26/2020
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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. Licensee's and husband's immunization records are up to date.

New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment

Incidental Medical Services (IMS) policy was discussed. 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

Applicant was reminded that all infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome), and that the Provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome. Applicant was also reminded that only children eating may be in high chairs and that car seats are utilized only for transportation. Applicant was provided an informational pamphlet titled, "Safe Sleep For Your Baby" during the inspection. Applicant was also provided an informational sheet titled, "What Does a Safe Sleep Environment Look Like?" to review and post at the facility.

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



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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2020
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: GOZEN FAMILY CHILD CARE
FACILITY NUMBER: 197494501
VISIT DATE: 02/26/2020
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Applicant was made aware that once licensed, it is the licensee’s responsibility to know the regulations as well as anyone who assists in providing care. Applicant was advised on how to access quarterly reports, forms, and regulations for Child Care and encouraged to read them online at www.ccld.ca.gov.

LPA discussed and provided the safe sleep for baby pamphlet. Each infant shall be constantly supervised and under direct visual observation by an adult person at all times. Under no circumstances shall any infant be left unattended. In order to visually observed and supervise sleeping infants there should be no obstruction to the view of the infants, which could include transparency walls and/or half walls. LPA recommend that infants sleep safest in crib with no bumpers, pillows, blankets, or toys, and on their backs, and every sleep time counts to reduce the risk of SIDS and other sleep related causes of infant death.

Lead Bill - Health & Safety Code 1596.7996. Licensee was made aware of AB 2370, requiring a licensed child day care center located in a building constructed before January 1, 2010, to have its drinking water tested for lead contamination and to let parents or legal guardians of children enrolled about the requirement to test and result of the tests.

Licensure is pending the following:

1) LPA's final file review

Exit interview was conducted and a copy of the report was provided.

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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2020
LIC809 (FAS) - (06/04)
Page: 5 of 5