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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494806
Report Date: 04/09/2021
Date Signed: 04/21/2021 02:59:00 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:SARKISYAN FAMILY CHILD CAREFACILITY NUMBER:
197494806
ADMINISTRATOR:VERA SARKISYANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 582-8888
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:14CENSUS: 0DATE:
04/09/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Vera SarkisyanTIME COMPLETED:
01:37 PM
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Due to the Governor’s Proclamation of State of Emergency, On 04/09/2021 at 8:45 am, Licensing Program Analyst (LPA) Antonio Almanza conducted an announced Prelicesning FaceTime Tele-Inspection and met with the applicant VERA SARKISYAN who guided LPA on a tour of the home located at 6635 CANTALOUPE AVE, VAN NUYS, CA 91405. The applicant is applying for a Large Family Child Care License to operate Monday to Friday from 9:00 am to 6:00 pm and serve children ages 2 year to 6 years of age. Fire Clearance approval was received on 03/21/2021. The single-story home is a 3-bedroom, 4 bathroom home with attached garage located on Cantaloupe Ave between Kittridge Ave and Archwood Ave. The home will be entered by parents though rough iron gate (Licensee states will be kept unlocked during pick up and drop off) at the front of the property. Parents will walk up to the front door of the home to drop off and pick up their children.

The applicant states the main care will be provided in the living room (located in the back of the home), dining room (located in the center of the home) two bedrooms locate in the hallway on the left-hand side of the home and the bathroom located in the entrance of the home. The off-limits areas of the home are as follows: kitchen, Master bedroom/bathroom/hallway area, bathrooms located in the hallway of the bedrooms, bathroom located in the front bedroom of the home, garage, swimming pool (located on the left back corner of the property), barbeque area, outside office and bathroom (located in the right back corner of the property). The off-limits areas of the home are inaccessible to children. Applicant states will provide meals and snacks to children in care. Applicant will use a cell phone for the family child care home and was advised that the cell phone should remain in the home while children are in care.

There is a fully equipped 2A10BC fire extinguisher located on the wall of the kitchen. The applicant places all sharp items / knifes and medication lock box in top kitchen cabinet inaccessible to children. LPA observed 14 cots. LPA observed first aid kit and wall with required postings in the dining room area. LPA observed an operating Smoke/CO combo detector in the bedrooms, living room and dining room. Cleaning supplies are kept under the kitchen sink with safety latch and garage (inaccessible). Applicant stated there are no weapons or firearms in the home and LPA did not observe any.

Pg 1.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
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 4
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: SARKISYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494806
VISIT DATE: 04/09/2021
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The backyard will be used by children in care. There is a covered area with concrete next to the entrance/exit of the daycare room and grass area for children to play in. On the right and left side of the home there are double gates making those areas inaccessible. There is a swimming pool in the left back corner of the yard covered with a 6-foot vinyl fence. There is less than 1 inch at the bottom of the fence and no visible space to the left side as there is a fence and large bushes. To the right of the fence there is a small building (office) with no space in between. The 6-foot-tall gate to the swimming pool opens outward and has latch at the top of the gate (about 1 inch from the top). The gate does not have a self-latching mechanism.

The following was discussed with the applicant:
-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. 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. -The fire extinguisher type 2A-10BC must be serviced annually. 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. -The smoking of tobacco in a private residence that is licensed as a family child care home shall be prohibited 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. -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. -LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.
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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
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: SARKISYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494806
VISIT DATE: 04/09/2021
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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
AB 1207: 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
Safe Sleep Links:
AAP:https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials, PIN 20-24-CCP: Recently Approved Safe Sleep Regulations In Effect. PIN 20-24-CCP: Recently Approved Safe Sleep Regulations In Effect
Incidental Medical Services: 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 Incidental Medical Services Include: Blood-Glucose Monitoring for Diabetic Children, Administering Inhaled Medication, Administering EpiPen Jr. and EpiPen or other Epinephrine Auto-Injectors, Glucagon Administration, Gastrostomy Tube Care (G-tube care), Insulin Injections Administration, Anti-Seizure Administration, and Emptying an Ileostomy Bag.

Applicant was emailed LIC311D and forms where explained:
Children’s Files must contain the following documentation:
LIC 9150 Parent Notification Additional Children in Care - LIC 282 Affidavit Regarding Liability Insurance - LIC 627 Consent for Emergency Medical Treatment - LIC 9166 Consent verification of Nebulizer Care - LIC 700 Identification and Emergency Information - LIC 995A Notification of Parent’s Rights - LIC 995E Caregiver Background Check Process - LIC 9212 Family Child Care Consumer Awareness Information - Immunization record - LIC 9224 Acknowledgement of Receipt of Licensing Reports

pg 3.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: SARKISYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494806
VISIT DATE: 04/09/2021
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The applicant was advised that, once licensed, the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, (Type A violation), a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. The applicant was made aware that a licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment.

The applicant was emailed a copy of the RAST (covid-19) email and TA was provided during the time of the visit. The information provided was reviewed and the self-assessment was explained.


The following is needed prior to approval for licensure. Applicant states will complete by 04/16/2021.
1. Qualifications for Large Family Child Care License: When applying for a license as a large family child care home, substantiation that the provider has at least one year of experience as a regulated small family child care home operator; or one year of experience as an administrator or director of or as a teacher at, a licensed child care center.

2. Self-latching mechanism needs to be installed in swimming pool gate.

3. Child safety latches installed in sliding closet door in 2 bedrooms that will be used by children.


4. Child Safety gate in kitchen making inaccessible while licensee is in kitchen.
5. Update facility Sketch
6. LPA to verify that all required documents are on file.

7. Licensure approval by Licensing Program Manager.

An Exit Interview was conducted, and a copy of this report was emailed to the applicant. It has been explained that a reply to the email shall be considered a substitute for the hard-copy signature.






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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio AlmanzaTELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4