197494809-4-20-2021-30-CC-MSIN-C29QBR-20210420120157

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494809
Report Date: 04/20/2021
Date Signed: 04/20/2021 12:03:27 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:	PETIKYAN FAMILY CHILD CARE		FACILITY NUMBER:	197494809
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	04/20/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Vergine Petikyan		TIME COMPLETED:	11:05 AM

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	Tele-Visit via Face-Time. The pre-licensing visit was conducted in Armenian. Licensee has been advised that an email shall be sent with the report attached, which has been reviewed during the Tele-Visit and a read receipt via email shall be considered an acknowledgement that they are in receipt of this form. This is an announced pre-licensing tele-visit conducted by Margarit Sislyan, Licensing Program Analysts (LPA) on 4/20/2021 at 10:00 AM with Applicants, Vergine Petikyan who guided analyst on a tele-tour at the facility. The applicant applied for change of location. This is one story single family home with 3 bedrooms and 1 bathrooms. Family members residing at the facility are: 1 adults and 2 children. The main care will be conducted in the living room. The one of the bedrooms will be used for child care purposes as well. The other two bedrooms are off limit. The home was inspected for safety, comfort, cleanliness, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Per facility sketch there is no pool or other bodies of water on the premises. During the tele-visit LPA did not observe pool or any other bodies of water on the premises. There are age appropriate toys and equipment on the premises. Applicant has provided proof of Preventative Health and Safety. CPR expires on 02/02/2022. The required smoke detectors and carbon monoxide detector are in operable condition Page 1 of 3

SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit Sislyan	TELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

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: PETIKYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494809
	VISIT DATE: 04/20/2021

NARRATIVE

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Applicant has submitted a disaster plan and demonstrated control of property at the above address by Lease Agreement. .
The following discussed: No smoking, no infant walkers, Johnny jumpers, exersaucers or any other item that falls into that category.

The LPA also discussed earthquake safety and necessity of drills, required forms for children’s files, facility files and posting requirements. Fingerprint clearance, transfer process and capacity / ratios. Regulation 102416.3 was explained and discussed
with applicant.

Novel Corona virus (COVID-19) Los Angeles County Department of Public Health Guidance for Early Childhood Education Providers was discussed.
Additional information available at: www.publichealth.lacounty.gov

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 LIC610A 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.

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SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit Sislyan	TELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: PETIKYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494809
	VISIT DATE: 04/20/2021

NARRATIVE

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● 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. 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.

LPA discussed 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is 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.

The following items are needed prior to licensure:
Required (2A10BC) fire extinguisher.

Exit interview

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SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit Sislyan	TELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

LIC809 (FAS) - (06/04)

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