197494668-10-15-2020-30-CC-DLOE-BUF26R-20201015170735

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494668
Report Date: 10/15/2020
Date Signed: 10/15/2020 05:08:04 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:	GARIBYAN & TSATURYAN FAMILY CHILD CARE		FACILITY NUMBER:	197494668
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	10/15/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:36 AM
MET WITH:	Nune Garibyan		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/15/2020 at 8:36 am Licensing Program Analyst (LPA) Deborah Lowe conducted a Tele Visit through Zoom with Applicant Nune Garibyan for the purpose of a pre-licensing inspection of property at 16648 Donmetz Street, Granada Hills, CA 91344. The purpose of this pre-licensing visit is to ensure the standards for a Family Child Care Home are being met in accordance to California Title 22 Regulations and California Health & Safety Codes. The application is for a small family child care license with a max capacity of 8. The applicant owns the home along with her husband Sevak Orudyan, and their one minor child therefore landlord consent is not required. Review of application and applicant stated her, her husband, their one minor child, and the co-applicant Ada Tsaturyan who is Nune's mother-in-law are the only residents of the home. Co-applicant Ada Tsaturyan was also present for the pre-licensing visit. Per the application, at this time, the ages the applicant wishes to provide services for are children 0 to 8 years old with the hours of operation as Monday to Friday 7:30 am to 5:30 pm. Applicant was informed that any changes to ages, hours and days of operation shall be submitted to the department for approval prior to initiation of changes. The residence is a single story family residence. Applicant toured LPA Lowe via Zoom tele visit through the residence and the grounds. LPA Lowe observed open front yard with no gate enclosures leading up to the front door. Entrance to facility will be through the front door. Front door was observed to have a video door bell. LPA Lowe observed the residence to have Living room with open floor plan to the kitchen, down hallway was four bedrooms, and a bathroom. Bedroom next to hallway bathroom was converted into a walk in closet with entry from the master bedroom. Second bathroom was observed off the living room.

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah Lowe	TELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

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 9

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: GARIBYAN & TSATURYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494668
	VISIT DATE: 10/15/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from page 1:

The living room, kitchen, bedrooms, bathroom in hallway, and bathroom off living room are all listed as OFF LIMIT areas. The home does not have a garage. Applicant stated the garage was converted into the master bedroom before they bought the home.

LPA Lowe observed the day care room entrance to be through a sliding glass door from the living room to the day care room. Day Care room has an exit door leading to the back yard. Door leading to the back yard was observed to have door handle closure with lock and an alarm when the door opens. LPA Lowe heard the alarm when door opened. Day care room was observed to have wood laminate flooring with a vinyl play mat. The room has a bin style toy shelf with age appropriate toys. Applicant stated she is adding a changing table, table for the children to sit at and chairs. Day care room has a bathroom. Bathroom was observed to have a toilet, stall shower with child proof latches on the door to prevent from opening, single sink with cabinet under. Applicant opened cabinet under sink, LPA Lowe observed clorox wipes and toilet cleaner, cabinet has a child proof latch. Bathroom has full size cabinet storage with child proof latches. Applicant opened cabinets, LPA Lowe observed emergency kits, first aid supplies, bottles water, diapers, and wipes. Fire extinguisher was observed on the wall near the bathroom door. LPA Lowe observed the size as 2A:10BC. Bathroom also has a door that leads to the laundry room LPA Lowe observed the door to have a lock, the laundry room has a door that leads to the backyard, door was observed to have a lock.

LPA Lowe observed smoke detector in the child day care room on the ceiling near the sliding door. LPA Lowe observed co-applicant Ada tested the smoke detector, LPA Lowe could hear the test. Carbon monoxide detector was located in the hallway of the home. Home is equipped with central heating and air.
Kitchen was observed to have an island siting area with three seats on one side and drawers on the other side. Cabinets and drawers were observed to have child proof latches and / or magnetic child locks. On walk in pantry with child lock on the door. Pantry was observed to have food items. Applicant opened drawers and cabinets. LPA observed items in cabinets and drawers, knives were located in top drawer of island drawer with magnetic child lock. Cabinets were observed to have pans, serving trays, towels, storage containers. Stove was observed to have a child proof latch for the oven door and the stove has an electronic control lock.

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah Lowe	TELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

LIC809 (FAS) - (06/04)

Page: 2 of 9

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: GARIBYAN & TSATURYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494668
	VISIT DATE: 10/15/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continue from page 2:

Applicant stated they will provide food for the children and request the parents provide for the infants. Applicant stated she will review food restrictions with the families during the enrollment.

LPA Lowe observed a fire place in the living room. Fire place has a mesh drape with a glass door closure with a child proof lock.

LPA Lowe observed the outside play area. Located in the backyard through a door from the day care room. Outside was observed to have artificial grass surrounded by concrete and one avocado tree. There is a circle shape pool in the backyard with black mesh fencing. Applicant used a measuring tape to measure fence, LPA Lowe observed applicant measure the fence. Fence height measures as 5' 2" , fencing was observed to surround the pool with a key lock system. LPA Lowe observed the applicant open the gate and allowed the gate to close on its own. LPA Lowe observed and heard an alarm when the gate was open. Mesh enclosure for the gate was observed to be anchor to the ground with no gap at the bottom. Outdoor lounge furniture was observed to be near the mesh enclosure for the pool, applicant moved the furniture and measured the distance after moving it. Distance from the furniture to the pool enclosure after moved was measured as 6'.

Facility Administration: Pediatric First Aid and CPR expires 03/2022 for the applicant Nune and 3/2021 for Ada, immunization's are on file.
102416 (c) Complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

A certificate of completion of a course or courses in preventive health practices as defined in subdivision (a) or certified copies of transcripts that identify the number of hours and the specific course or courses taken for training. (8 hours required) Preventative Health and Safety practices completed on 12/4/19 for Nune and 9/15/19 for Ada and placed in facility file.

·Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately.

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah Lowe	TELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

LIC809 (FAS) - (06/04)

Page: 3 of 9

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: GARIBYAN & TSATURYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494668
	VISIT DATE: 10/15/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from page 3:

·If the aforementioned is not adhered to, a Civil Penalty of up to $500, per non-cleared adult will be assessed immediately. Please advise your analyst of any person who will be visiting regularly or for longer than one week.

·In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.
·Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. The family day care home shall maintain documentation of the required immunization's or exemptions from immunization, as set forth in this section, in the person’s personnel record that is maintained by the family day care home.
·A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.

·Annual fees must be paid promptly and by the due date or a late fee shall be assessed, and/or the License shall be terminated. (If paying by check please make sure to write facility number on check to ensure that payment is applied to your facility number)
· The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries should be replaced.
·Changes should be reported the to the Department as soon as they occur such as construction and remodeling.
·Telephone number changes and/or if you move from home.

·Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

·Fire and safety drills must be performed every six months and documented for review by the Department. (Child care Fire Drill log provided to applicant).

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah Lowe	TELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

LIC809 (FAS) - (06/04)

Page: 4 of 9

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: GARIBYAN & TSATURYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494668
	VISIT DATE: 10/15/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from page 4:

·There is an effective 24/7 ban on smoking tobacco in a home that is licensed as a family day care home, and in those areas of the family day care home where children are present. ·Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
·Saucer chairs, bouncers, walkers, or any similar items are prohibited. (Flyer example of what these items may look like given to applicant today)
·All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
·Emergency Disaster Plan, Parent’s Rights Poster and the Facility License are required to be posted.
·LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov (Applicant currently receives quarterly updates)

The applicant 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 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: childcareadvocatesprogram@dss.ca.gov (Child Care Advocate Program Flyer given to applicant today).

·There is an effective 24/7 ban on smoking tobacco in a home that is licensed as a family day care home, and in those areas of the family day care home where children are present. ·Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
·Saucer chairs, bouncers, walkers, or any similar items are prohibited. (Flyer example of what these items may look like given to applicant today)
·All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
·Emergency Disaster Plan, Parent’s Rights Poster and the Facility License are required to be posted.
·LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov (Applicant currently receives quarterly updates)

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah Lowe	TELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

LIC809 (FAS) - (06/04)

Page: 5 of 9

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: GARIBYAN & TSATURYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494668
	VISIT DATE: 10/15/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from page 5:
The applicant 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 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: childcareadvocatesprogram@dss.ca.gov (Child Care Advocate Program Flyer given to applicant today)

AB 1207: Mandated Reporter Training (Health and Safety Code 1596.8662 )-Beginning on January 1, 2018, this law requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. Website: www.mandatedreporterca.com. Followed by the general training module, the Child Care Providers module is a three hour training that includes eight sections. Mandated Reporter Training on 01/16/2020 (AB 1207 printout and Reporting Child Abuse and Neglect flyer provided to Applicant).

Applicant will not be providing IMS incidental medical services at this time. However, if she decides to do so she will inform CCLD-Child care Licensing and submit a plan prior to doing so.

IMS Include: Blood-Glucose Monitoring for Diabetic Children, Administering Inhaled Medication, Administering Epinephrine Auto-Injectors, Glucagon Administration, Gastrostomy Tube Care (G-tube care), Insulin Injections Administration, Anti-Seizure Administration, and Emptying an Ileostomy Bag.

Incidental Medical Services (IMS) policy was discussed 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
Safe Sleep Links:
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah Lowe	TELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

LIC809 (FAS) - (06/04)

Page: 6 of 9

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: GARIBYAN & TSATURYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494668
	VISIT DATE: 10/15/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from page 6:
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

Safe sleep for your baby pamphlet and what does safe sleep look like wall flyer provided to applicant. Safe Sleep new flyer (5/23/2019) also given to applicant.

SIDS & SHAKEN BABY SYNDROME INFORMATION: LPA discussed safe sleep for infants with applicant: Infants must be placed on their backs and must be physically checked every 15 minutes to gauge temperature and ensure they are breathing. Applicant reviewed both items provided and understands the guidance of safe sleep practices. LPA discussed flyer given today (Never Shake a Baby) Applicant reviewed flyer and understands the preventive practices of shaken baby syndrome and abusive head trauma.

FORMS TO BE POSTED
· LIC203 Facility License
· LIC 610A Emergency Disaster Plan
· LIC 9148 Earthquake Preparedness Checklist
· PUB394 Notification of Parents Rights Poster

Children’s records requirements:
· LIC 700 Identification and Emergency Information
· LIC 627 Consent for Emergency Medical Treatment
· LIC 282 Affidavit Regarding Liability Insurance
· LIC 9150 Parent Notification Additional Children in Care
· Immunization record
· PUB 72- Family Child Care Consumer Guide
· LIC 995A Notification of Parent’s Rights
CDPH 286 (Immunization Blue Card)

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah Lowe	TELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

LIC809 (FAS) - (06/04)

Page: 7 of 9

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: GARIBYAN & TSATURYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494668
	VISIT DATE: 10/15/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from page 7:

FACILITY RECORDS:
· LIC 624B Unusual Incident/Injury Report
· LIC 9040 Child Care Facility Roster
· LIC 9052 Employee Rights,
· LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
· LIC 9149 Landlord Consent Form, if you plan to care for more than 6 children for a Small
· LIC 9151 Property Owner/Landlord Notification Form
· Proof of current pediatric CPR and First Aid Certificates

· Copy of your deed or lease/rental agreement

· Documentation of Fire and Disaster drills
· Proof of immunization's against pertussis (TDAP), measles (MMR), and influenza
· Mandated Reporter certificate – www.mandated reporterca.com – renewed every two years.

Other documents given to Applicant: California Car Seat Law changes effective January 1, 2017, Ratio flyers for both small and large Family Child Care Homes, California Childcare Health Program Healthy Beverages in Child Care, Prohibited Items in child care family homes, Effects of Lead Exposure (CDSS Flyer), Child Care Advocate Program support sheet and “Keep me safe” printout.

A packet that includes the documents listed above were provided and discussed.

Licensee was made reminded that it is the licensee’s, as well as anyone who assists in providing care responsibility to know the regulations. Licensee was advised on how to access quarterly reports, forms, and regulations for Child Care online at www.ccld.ca.gov. Licensee was also encouraged to read the Child Care quarterly updates every season as they come out to stay informed of any changes or updates to statutes and regulations. Applicant currently receives quarterly updates from CCLD/Childcare.

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah Lowe	TELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

LIC809 (FAS) - (06/04)

Page: 8 of 9

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: GARIBYAN & TSATURYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494668
	VISIT DATE: 10/15/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from page 8:

The following items are pending prior to licensure to be completed by: 10/30/2020 via LPA email pending a follow up visit to be scheduled thereafter items are received.

1. Take pictures of the pool, pool mesh fencing, and surrounding area of the pool.
2. Prepare declaration for a plan to maintain the integrity of the pool fencing.
3. Provide manufacture information about the mesh fencing around the pool. What is the type of material and maintenance requirements for it.
4. Pictures of napping maps or cots once they arrive.

An exit interview was conducted, and a copy of this report was provided to the Applicant, Nune Garibyan. Once documents requested received a follow pre-license inspection may need to be conducted and a Final decision of License issuance will be determined by the department unit Licensing Program Manager.

SUPERVISOR'S NAME: Karren Starks	TELEPHONE: (434) 301-3069
LICENSING EVALUATOR NAME: Deborah Lowe	TELEPHONE: (424) 301-3016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

LIC809 (FAS) - (06/04)

Page: 9 of 9