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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494501
Report Date: 04/19/2022
Date Signed: 04/19/2022 11:02:13 AM


Document Has Been Signed on 04/19/2022 11:02 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
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:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:14CENSUS: 7DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Natalie Gozen/LicenseeTIME COMPLETED:
11:00 AM
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On 04/19/2-22 Licensing Program Analyst (LPA) Silva Garibyan conducted an unannounced Annual Required Inspection and was met by Licensee, Natalie Gozen (Zazhytska). Also present were Staff #1 (S1) and Staff #2 (S2). Days and hours of operation are M-F 8:00 AM – 6:00 PM.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed and Licensee confirmed that the living room, dining room, and the step-down bathroom are used for providing care and are accessible to children. 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 children 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 ( 10 and 7 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. 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.

SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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: GOZEN FAMILY CHILD CARE
FACILITY NUMBER: 197494501
VISIT DATE: 04/19/2022
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Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

The fireplace located in the step-down family room is made inaccessible by a screen and will not be in use during daycare hours. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (818) 358-5980.

There are currently no infants enrolled in care. LPA discussed Safe Sleep Regulations with licensee.

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 07/21/21. Licensee’s pediatric CPR/First Aid expires in December of 2021. 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.

SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
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: GOZEN FAMILY CHILD CARE
FACILITY NUMBER: 197494501
VISIT DATE: 04/19/2022
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Incidental Medical Services (IMS) are / are not currently 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.

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, no deficiencies are cited.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3