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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494809
Report Date: 12/07/2021
Date Signed: 12/07/2021 08:06:58 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 CAREFACILITY NUMBER:
197494809
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
12/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Vergine PetikyanTIME COMPLETED:
10:30 AM
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Margarit Sislyan, Licensing Program Analyst (LPA) arrived at the facility to conduct a site inspection. Licensee applied for increase of capacity.

LPA observed 4 children were present at the facility along with licensee and licensee's assistant (S1)

LPA toured the facility inside and outside. This is 3 bedroom and 1 bathroom single family home. The living room and one of the bedrooms were used for day care purposes. The other rooms were off limit.

The fireplace in the living room was covered with chalk board.

LPA observed the facility complied with Title 22 regulations. The fire extinguisher, smock detector and carbon monoxide detectors were in operable condition.

The CPR/First Aid certificate was updated with expiration date 02/01/2022. The Child Abuse Mandatory training was completed on 11/08/2021.

The fire clearance was granted, and the report is in the file.

The approval of license for Large Family Child Care Home pending for file review.

Exit interview.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Margarit SislyanTELEPHONE: (424) 430-3049
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
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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