198015912-7-27-2022-33-CC-NTCG-CGQSHM-20220727135345

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198015912
Report Date: 07/27/2022
Date Signed: 07/27/2022 01:53:59 PM

Document Has Been Signed on 07/27/2022 01:53 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:	BOULGHOURJIAN FAMILY CHILD CARE		FACILITY NUMBER:	198015912
ADMINISTRATOR:	BOULGHOURJIAN, EMA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 636-4684
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	14	CENSUS: 5	DATE:	07/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Ema Boulghourjian - Licensee		TIME COMPLETED:	02:06 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

Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced annual random inspection to the above facility. At 12:15pm, LPA met with licensee, Ema Boulghourjian. Also present during this inspection, is Licensee’s assistant. The licensee states that she currently has 5 children enrolled. A current children’s roster is available and is current. Licensee’s hours of operation are 8am-4pm, Monday-Friday.

This is a one-story home which consists of 4 bedrooms, 2 bathrooms, kitchen, dining room, living room, front den, back den (daycare room) detached garage, front yard and backyard (fenced). The children use 3 Bedrooms for nap, back den (daycare room), bathroom, and backyard. Per licensee, areas off limits to children and parents include: front den, living room, dining room, kitchen, Master bedroom, detached garage, and front yard. All areas identified on the facility sketch were inspected. The licensee provides food for children in care.

The licensee states that 2 adults and 0 children currently live in the home. Persons living in the home are identified on the attached LIC811. Licensee states that she currently has two assistants. All individuals present in the home have obtained a criminal record clearance or exemption prior to working, residing or volunteering in a licensed home. Per licensee, there are no weapons, firearms or bodies of water on the premises.

PHYSICAL PLANT

At 12:20pm, LPA was lead on a tour of the facility by the licensee. The tour began in the back, as the children are dropped off in the back. It leads straight into the back den which is used as a daycare room. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License are observed to be posted. There are age appropriate toys and equipment present in the room. There is a diaper changing table present in the room. Tour continued to the bathroom which was clean and free of hazards. The cabinet underneath the sink had safety latches on it. Detergents, cleaning compounds, medications, and other items which could pose a danger are inaccessible to children. REPORT CONTINUES PAGE 1 of 4

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan Tcheng	TELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

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 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: BOULGHOURJIAN FAMILY CHILD CARE	FACILITY NUMBER: 198015912
	VISIT DATE: 07/27/2022

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

At 12:40pm, a fire extinguisher was observed. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 03/17/2022, as indicated on service tag. Per State Fire Marshall standards, fire extinguishers shall be serviced annually. Smoke and carbon monoxide detectors were tested and are operable. There are first aid supplies available. LPA next reviewed the two bedrooms used for nap. There were 4 cribs available in the first bedroom and 2 cribs in the second bedroom. The third bedroom was reviewed for child care for the use as a nap room. There are mats and cots available for children old enough to use them for nap time. The licensee states that a cell phone is used and stays at the facility during operating hours. Per licensee, one of the bedrooms will be used as an area for an ill child until an authorized representative comes to pick up child. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock.

At 12:50pm, LPA observed the back yard area. The outdoor play area was observed to be fenced. At this time, children are using the back yard for outdoor play time. There are age appropriate toys and equipment for children to use. There are bikes for riding and a small slide. There is ample space for children to run around. The licensee is observed to be operating within the license capacity limitations.

FACILITY RECORDS:

The licensee and other personnel have completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 04/2024. Licensee and other personnel have completed mandated reporter training that expires 07/2024. The licensee does have proof of immunization against influenza, tuberculosis, pertussis, and measles. Children’s records were reviewed, including but not limited to, a copy of the emergency information card that contains all the information specified by regulation.

The following was discussed:

-Individuals who are 18 years of age or older living in the home must be finger print cleared prior to being in the presence of the children in care. Individuals within one month of their 18th birthday must be fingerprinted immediately.
-There are no pets on the premises.
-Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that falls into these categories are not permitted in a family child care facility.
-Smoking is prohibited in a license family child care home.
REPORT CONTINUES PAGE 2 of 4

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan Tcheng	TELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

LIC809 (FAS) - (06/04)

Page: 2 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: BOULGHOURJIAN FAMILY CHILD CARE	FACILITY NUMBER: 198015912
	VISIT DATE: 07/27/2022

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

Infant Care: Licensee states that they are currently caring for infants. LPA advised the licensee to sleep infants where they can be directly supervised at all times and advised the licensee against sleeping infants in a separate room. Licensee states that infants sleep in the bedrooms with the doors kept open and staff will be supervising the whole time. LPA provided the licensee with a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics and Helping you to reduce the risk of SIDS. LPA consulted and explained Child Abuse Reporting, Updated Parent’s Rights Poster with Complaint Hotline information, Never Shake a Baby, Sudden Infant Death Syndrome (SIDS), and Safe Sleeping practices. PIN 20-24-CCP was provided and explained during the inspection.

Incidental Medical Services (IMS):

The licensee states that she will provide IMS. Per licensee, there are no children enrolled that require IMS at this time. 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.

LPA observed COVID Health and Safety Protocols being followed at the facility.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

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/

REPORT CONTINUES PAGE 3 of 4

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan Tcheng	TELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: BOULGHOURJIAN FAMILY CHILD CARE	FACILITY NUMBER: 198015912
	VISIT DATE: 07/27/2022

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

At this time, the licensee is in compliance with California Code of Regulations Title 22. No deficiencies cited.

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

Exit interview was conducted with Licensee Ema Boulghourjian, at 1:45pm. Copy of report was provided.

END OF REPORT PAGE 4 of 4

SUPERVISOR'S NAME: Claudia Guangorena	TELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Nolan Tcheng	TELEPHONE: (323) 240-6201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

LIC809 (FAS) - (06/04)

Page: 4 of 4