197494828-6-24-2021-30-CC-SGAN-C4AML5-20210624094146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494828
Report Date: 05/05/2021
Date Signed: 06/24/2021 09:41:58 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:	GRIGORYAN FAMILY CHILD CARE		FACILITY NUMBER:	197494828
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	05/05/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Karine Grigoryan/applicant		TIME COMPLETED:	03:30 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	Pre-Licensing Visit Conducted In Armenian On 05/05/2021 at 12:30 PM Licensing Program Analyst (LPA) Silva Garibyan conducted an announced Pre-Licensing tele-inspection via FaceTime due to the COVID-19 pandemic shelter-in-place orders in the state of California. The purpose of the meeting was to ensure that health, safety and personal rights as required by Title 22 Regulations governing California Family Child Care homes will be met by the Licensee. This is an application for a Small Family Child Care Home. The family child care home will operate Monday thru Friday 6:00 AM. to 12:00 AM. LPA met with Licensee, Karine Grigoryan, and was guided on a tour of the indoor and outdoor of the home. Licensee has no pets. Licensee's home is a single story 3 bedroom, 1 bathroom home with living room, kitchen, laundry room, and attached garage. The main entry door will be used to enter the facility. Applicant's bedroom and the garage are off limits to the children in care. Children will eat and sleep in the living room and in two bedrooms. There is an in-ground pool on the premises located in the back yard of home with fencing around the perimeter. Pool was inspected and fence was measured by applicant during today’s visit. LPA observed the pool fencing to be 5 feet high. One side of the pool is enclosed by the iron fence. The iron fence has self latching gate that swings towards the pool and has a self latching device that is located no more than 6 inches from the top of the fence. The three sides are enclosed by the property walls. The iron fencing is sturdy and capable of withstanding the impact of children's toys including bicycles. There are no other bodies of water on the premises. Pool does not meet title 22 regulation code 102417 (g)(5)(A) Page 1 of 5

SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva Garibyan	TELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

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 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: GRIGORYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494828
	VISIT DATE: 05/05/2021

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

Family members residing in the home include the licensee only. Applicant has submitted a disaster plan and completed preventive health and safety/Childhood Nutrition training/Lead Poisoning Prevention. The required fire extinguishers (2A10BC) and smoke/Carbon Monoxide detectors are in operable condition.
Children will utilize the back yard to play. The front and back yards are fully fenced. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Applicant states there are no firearms or weapons of any kind in the facility at this time. The First Aid kit was observed and complete. The applicant has current pediatric CPR/First Aid training that will expire in April of 2023. There are age appropriate toys and equipment for the children.

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 LIC 610A 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.
● 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.
Page 2 of 5

SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva Garibyan	TELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

LIC809 (FAS) - (06/04)

Page: 2 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: GRIGORYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494828
	VISIT DATE: 05/05/2021

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

Mandatory Forms for the children’s files: (LIC 282 Affidavit Liability Insurance, LIC 627/Consent for Medical Treatment, LIC 700/ID and Emergency Information, LIC 995A/Parent's Rights, LIC995E/Caregiver Background Check, LIC 9150/Parent Notification, LIC 9212/Parent'esponsibilities, PM 286/Immunization (Blue) Card).

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.

Requirements for fire drills, earthquake drills, and documentation for both. Role and responsibilities of being a mandated reporter were reviewed. The applicant was advised how to access forms and Regulations for Family Child Care online at www.ccld.ca.gov. Regulation prohibits the smoking of tobacco in a private residence licensed as a family child care home during the hours of operation. State law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category.

The following was thoroughly discussed with the licensee:

Assembly Bill 633: Upon receipt by the licensee, licensees are to provide to parents/guardians the following: Copies of any licensing reports that document a Type A citation- this includes facility visits and substantiated complaint investigations; copy of licensing documents pertaining to a conference conducted by a local licensing agency management representative and the licensee of this family child care home in which issues of noncompliance are discussed or copies of a summary of an accusation indicating the Department's intent to revoke the facility's license. Copies of any of the above licensing documents the licensee has received in the prior 12 months shall be provided to parents/guardians of newly enrolled child at the facility.

Senate Bill 792: This bill, commencing September 1, 2016, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles. Applicant's immunization records are up to date. page 3 of 5

SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva Garibyan	TELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

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: GRIGORYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494828
	VISIT DATE: 05/05/2021

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

New Immunization Requirement: Law enacted by SB 277, beginning January 1, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into child care or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint. .
New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment

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

Applicant was reminded that all infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome), and that the Provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome. Applicant was also reminded that only children eating may be in high chairs and that car seats are utilized only for transportation. Applicant was provided an informational pamphlet titled, "Safe Sleep For Your Baby" during the inspection. Applicant was also provided an informational sheet titled, "What Does a Safe Sleep Environment Look Like?" to review and post at the facility.

The licensee 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 in order 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 Address: childcareadvocatesprogram@dss.ca.gov Page 4 of 5

SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva Garibyan	TELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

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: GRIGORYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494828
	VISIT DATE: 05/05/2021

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

Mandated Reporter: Beginning on January 1, 2018, AB 1207, 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. Armenian speaking only.
Applicant was made aware that once licensed, it is the licensee’s responsibility to know the regulations as well as anyone who assists in providing care. Applicant was advised on how to access quarterly reports, forms, and regulations for Child Care and encouraged to read them online at www.ccld.ca.gov.
LPA discussed and provided 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.

Applicant was informed that the following is pending licensure and needs to be corrected within 30 days from the date of this report

1) Pool gate shall swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate.
2) Revised LIC508 for applicant

An exit interview was conducted and a copy of this report will be provided via email to licensee.

Page 5 of 5

SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva Garibyan	TELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

LIC809 (FAS) - (06/04)

Page: 5 of 5