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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198004693
Report Date: 03/25/2022
Date Signed: 03/25/2022 03:10:06 PM


Document Has Been Signed on 03/25/2022 03:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:ST. GREGORY'S A & M HOVSEPIAN CHILD CARE CTR, INC.FACILITY NUMBER:
198004693
ADMINISTRATOR:ARPY JAHJAHFACILITY TYPE:
850
ADDRESS:2215 E. COLORADO BLVD.TELEPHONE:
(626) 578-1343
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:88CENSUS: 60DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Arpy Jahjah - DirectorTIME COMPLETED:
03:17 PM
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Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced random annual inspection. Upon arrival at 10:20am, LPA met with Director Arpy Jahjah. At 10:25am, Director led LPA on a tour of the facility. This is a Preschool program with a Toddler Option, which consists of 7 classrooms (2 of which are Toddler). Per licensee, there are currently 74 enrolled in the program. Facility shares property with a K-8 School. Hours of operation for this facility are 8am-5:30pm, Monday to Friday.

Licensing staff observed all required forms/publications to be posted in the office and in hallway. Snack menus were reviewed to ensure that they are being posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days are available upon request.

PHYSICAL PLANT: At 10:27am, LPA entered and inspected Red 1 (2/3s): 9 children with 2 staff members, Red 2 (2/3s): 10 children with 2 staff members, Blue 1 (3/4s): 13 children with 2 staff members, Blue 2 (3/4s): 11 children with 2 staff members, Green (Pre-K): 7 children with 2 staff members, Yellow 1 (Younger Toddlers): 5 children with 2 staff members, and Yellow 2 (Older Toddlers): 5 children with 2 staff members. In each classroom, LPA observed disinfectants, cleaning solutions, medication and other items that are dangerous to children, were inaccessible to children. Furniture and equipment are in good condition, free of sharp, loose, or pointed parts. All floors are clean and safe. LPAs reviewed the storage of napping equipment. Napping equipment was observed to be cots for all classrooms at the facility. All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair. Trash cans used to discard food have tight fitting lids. The facility was observed to be free of flies, other insects and rodents. Sufficient individual storage space for children was observed and each child has a cubby. Drinking water was readily available indoors. At this time, the office is used as an isolation area. A cot is available for an ill child to rest on. First Aid supplies are available and complete. Facility has a functioning carbon monoxide detector that meets statutory requirements. Director states there are no weapons, firearms, or bodies of water on the premises.


REPORT CONTINUES PAGE 1 of 4
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan TchengTELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: ST. GREGORY'S A & M HOVSEPIAN CHILD CARE CTR, INC.
FACILITY NUMBER: 198004693
VISIT DATE: 03/25/2022
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At 10:35am, a fire extinguisher was observed. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 06/16/2021, as indicated on service tag. Per State Fire Marshall standards, fire extinguishers shall be serviced annually. LPA observed multiple fire extinguishers throughout the facility. There are three available restrooms for children in care to use. One is attached to the toddler classroom for children who are transitioning. All toilets, hand washing, and bathing facilities are safe, sanitary and are operating properly. At 10:45am, while inspecting the Toddler classrooms, LPA observed the diaper changing table to be at least one inch thick, with raised sides of at least 3-inches, and within arms reach of the sink. At 10:50am, the kitchen was reviewed. All food preparation areas and food storage areas are kept clean and are free of litter, rubbish and rodents and/or any other vermin. Snacks were reviewed for availability, quantity and appropriateness to children in care. This facility provides lunch, am snack, and pm snack.

OUTDOORS: At 10:53am, LPAs reviewed the outdoor play area. Outdoor playground equipment is in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment, swings, slides, and similar equipment are cushioned with material that absorbs a fall. There is one outside play space for Toddlers in care that is physically separate from the Preschool outdoor area. There are playhouses, climbing structures, tricycles, ball pit, and age appropriate toys. The Preschool outdoor area has a small and a large play structure, rock climb wall, play cars, and age appropriate toys for children in care. Teacher-child ratios were observed to be in accordance with Title 22 regulations. Staff names were recorded. All children were observed to be under visual supervision of a teacher during tour. The Licensee is within the conditions, limitations, and capacity specified on the license. All areas were identified on the Facility Sketch were inspected.

FACILITY RECORDS: Sign in and out sheets were reviewed through their ProCare app, to ensure that the person who signs the child in and out uses their full legal signature and records the time of the day. Disaster drills have been conducted at least every 6 months. Staff files were reviewed for a health screening report and immunizations that meet regulatory requirements. During record review at 12:55pm, LPA observed that 7 of 15 staff files did not have a LIC503 Health Screening Report form. LPA also observed that 12 of 15 staff files did not have proof of complete immunization records present. LPA discussed with Director the importance of having these forms completed and submitted prior to their start date.


REPORT CONTINUES PAGE 2 of 4
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan TchengTELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: ST. GREGORY'S A & M HOVSEPIAN CHILD CARE CTR, INC.
FACILITY NUMBER: 198004693
VISIT DATE: 03/25/2022
NARRATIVE
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Criminal Record Clearance for adults and verification of CPR/First Aid and health preventative practices documentation was reviewed. The name of the child care center director or fully qualified teacher(s) designated to act in the director's absence is on file. Educational background, training, and/or experience for each staff present are on file and were reviewed. At 1:15pm, LPA observed that 4 of 15 staff files did not have a renewed Mandated Reporter Child Care Provider (AB1207) Training proof of completion. LPA discussed with Director the importance of ensuring the facility staff retake the training every two years. A random sample of Children’s Records were reviewed to ensure that they are complete.

INCIDENTAL MEDICAL SERVICES:


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

During this inspection LPA discussed PIN 20-06 CCP, Social And Physical Distancing Guidance And Healthy Practices For Child Care Facilities In Response To The Global Coronavirus (COVID-19) Pandemic Written In Collaboration With The California Department Of Education and reviewed Child Care Covid-19 Self Assessment.

LPA discussed the safe sleep regulations with licensee Director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

REPORT CONTINUES PAGE 3 of 4

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan TchengTELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: ST. GREGORY'S A & M HOVSEPIAN CHILD CARE CTR, INC.
FACILITY NUMBER: 198004693
VISIT DATE: 03/25/2022
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Licensee was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA advised the licensee how to access forms, regulations and quarterly updates on line at: www.ccld.ca.gov. AB1207 Mandated Child Abuse Reporting – Implementation was discussed with Licensee. Website provided: http://mandatedreporterca.com/

The deficiencies listed on the following pages were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809D for deficiencies that are being cited and need to be cleared to protect the children’s health & safety.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative.

Exit interview was conducted with Director Arpy Jahjah, at 3:03pm, and Plan of Corrections were reviewed and developed. Copy of report was provided.

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan TchengTELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/25/2022 03:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: ST. GREGORY'S A & M HOVSEPIAN CHILD CARE CTR, INC.
FACILITY NUMBER: 198004693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 12 out of 15 Staff files, Staff #1-4, 6-10, & 13-15, did not have proof of immunization records, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2022
Plan of Correction
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Per Director, they will tell Staff #1-4, 6-10, & 13-15 to provide their immunization record. Director will submit records to LPA by POC date.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 15 Staff files, Staff #7, 8, 11, & 12, did not have proof of Mandated Reporter Child Care Provider (AB1207) completed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2022
Plan of Correction
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Per Director, they will have Staff #7, 8, 11, 12 complete the Mandated Reporter Child Care Provider (AB1207) Training as soon as possible. Staff were informed during the inspection and director will remind them tonight. Director will submit proofsof completion to LPA by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan TchengTELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 03/25/2022 03:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: ST. GREGORY'S A & M HOVSEPIAN CHILD CARE CTR, INC.
FACILITY NUMBER: 198004693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 7 out of 15 Staff files, Staff #3, 4, 10-12, 13, & 15, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2022
Plan of Correction
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Per Director, they will notify Staff #3, 4, 10-12, 13, & 15 to have their physician complete the lIC503 with them. Director will submit copies of completed forms by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan TchengTELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6