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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494563
Report Date: 06/14/2021
Date Signed: 08/05/2021 11:27:10 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:DERDZAKYAN FAMILY CHILD CAREFACILITY NUMBER:
197494563
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
06/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Arevik Derdzakyan/LicenseeTIME COMPLETED:
01:30 PM
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On 06/14/2021 Licensing Program Analyst (LPA), Silva Garibyan conducted an unannounced Annual Required Inspection and was met by Licensee, Arevik Derdzakyan. Also present was Staff #1 (S1). Licensee is Armenian Speaking. Days and hours of operation are Monday through Friday 8:00 AM to 10:00 PM.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed and Licensee confirmed that the living room, the day care room/bedroom, and the bathroom in the hall way are used for providing care and are accessible to children. All other rooms and the converted garage are off-limits and made inaccessible by use of safety gates and safe knobs. There is no swimming pool or other bodies of water on the premises.

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

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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: DERDZAKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494563
VISIT DATE: 06/14/2021
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There are no firearms or ammunition on the premises. All poisons are kept in a locked storage area in the laundry room. 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 screen and will not be in use during day-care hours. 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 (323) 788-1969.

There is one infant in care. LPA discussed Safe Sleep Regulations with licensee. There is a play yard for the infant in care. The play yard is kept free from all loose

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

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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: DERDZAKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494563
VISIT DATE: 06/14/2021
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articles and objects while infant is sleeping, and there are no objects hanging above or attached to the play yard. The Infant is not swaddled while in care. Provider physically checks on sleeping infant 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. Infant 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.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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: DERDZAKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494563
VISIT DATE: 06/14/2021
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LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee is Armenian speaking only and has not completed the Mandated Reporter Training. Licensee’s pediatric CPR/First Aid expires on 06/02/23. 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 have a criminal record clearance or exemption. There are no excluded individuals present at this home. Incidental Medical Services (IMS) is 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.

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

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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: DERDZAKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494563
VISIT DATE: 06/14/2021
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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.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.

The licensee is applying for an increase of capacity; Large Family Child Care Home license for a maximum capacity of 14. The licensee has an approved fire clearance ( Fire Clearance granted on 05/26/21 by LA City Fire Prevention Bureau, received by department on 06/09/2021).

Capacity and Ratios: The licensee has applied for a capacity increase for a large family . The Maximum capacity is 12 with no more than 4 infants and a qualified assistant. Without a qualified assistant the license reverts back to the requirements for a small family childcare. Optional care may be provided for a maximum capacity of 14 children with no more then 3 infants, 2 school age children and a qualified assistant. School age children must be 1 age 6 yrs and 1 in

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

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5