198017479-11-6-2019-33-CC-AEIN-BHNS5D-20191106123412

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198017479
Report Date: 11/06/2019
Date Signed: 11/06/2019 12:34:16 PM

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:	MY WONDER YEARS PRESCHOOL		FACILITY NUMBER:	198017479
ADMINISTRATOR:	DIANA MENEDJIAN		FACILITY TYPE:	850
ADDRESS:	312-324 RIVERDALE DRIVE		TELEPHONE:	(818) 247-9900
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91204
CAPACITY:	130	CENSUS: 103	DATE:	11/06/2019
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Diana Menedjian, Director and Lusine Saakyan, site director		TIME COMPLETED:	12:50 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 Analysts (LPA) Anomeh Eivazian and Alanna Gontarek conducted an unannounced case management incident inspection today, due to an incident that occurred on Monday 10/07/19. LPAs met with Lusine Saakyan, Director and Diana Menedjian, Director who assisted LPAs with a tour of the facility. inspection. Alleged Incident took place on Monday 10/07/19. Incident was reported via telephone same working day. Original LIC 624 Unusual Incident/Injury Report form was received by the Department within 7 days. The written incident report was received by mail on Thursday 10/10/19. The incident report was dated for Thursday 10/10/19. The facility reported the incident within the required 24 hour time frame. During this inspection LPAs watched recorded footage of incident on director, Diana Menedjian's phone. Per watched video LPA Eivazian interviewed staff#1. Per staff #1 interview and LPA's watched video, while child#1 was playing outside by slide area (pictures were taken), child#1 was running , tripped over, landing face forward holding body weight on both arms. Per staff#1, child#1 complained of pain in right forearm right away, child#1 was taken to the office, ice was applied and parents were called. Per site director, child#1 was taken to doctor and sustained green stick fracture and cast was placed on child#1's forearm. Child #1 returned to school on 10/15/19. Ratio and staffing were in accordance of Title 22 Code of Regulations at the time of the incident. No deficiencies were cited on this date. LPA issued the Confidential Names List (LIC 811) to the licensee during this inspection. The Confidential Names List documents the staff and children involved with the incidents documented in this report. REPORT CONTINUES ON THE NEXT PAGE 1 OF 2

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 854-8930
LICENSING EVALUATOR NAME: Anomeh Eivazian	TELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2019

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

FACILITY NAME: MY WONDER YEARS PRESCHOOL	FACILITY NUMBER: 198017479
	VISIT DATE: 11/06/2019

NARRATIVE

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At this time, there is not a preponderance of evidence that shows that the facility was in violation with Title 22 Regulations when these incident occurred. Therefore, there are no deficiencies being cited.

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. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted with Diana Menedjian, director including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.

REPORT END 2 OF 2

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 854-8930
LICENSING EVALUATOR NAME: Anomeh Eivazian	TELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2019

LIC809 (FAS) - (06/04)

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