198020748-5-28-2021-33-CC-JDOY-C3FLQA-20210528085714

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198020748
Report Date: 05/27/2021
Date Signed: 05/28/2021 08:58:39 AM

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:	KHODAGULYAN FAMILY CHILD CARE		FACILITY NUMBER:	198020748
ADMINISTRATOR:	MONIKA KHODAGULYAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 580-8989
CITY:	MONTROSE	STATE: CA	ZIP CODE:	91020
CAPACITY:	14	CENSUS: 0	DATE:	05/27/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:48 PM
MET WITH:	Monika Khodagulyan		TIME COMPLETED:	05:04 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	This was an announced pre-licensing inspection to evaluate facility for a Family Child Care Home license conducted by Licensing Program Analyst (LPA) Justin Dorsey. Due to COVID-19 and precautionary measures, this pre-licensing inspection was conducted with applicant Monika Khodagulyan, via a tele-inspection by use of FaceTime. The applicant was formerly licensed with a family childcare home at 2615 Manhattan Ave, Montrose, Ca 91020 (#198019045). Per applicant she is the only adult living in the home, the applicant states her son also live in the home with her. The applicant will operate from Monday through Friday, from 7:00 a.m., to 6:00 p.m. Ages to care for will be from 0 months - 6 years old. During this tele-inspection the applicant took LPA on a tour of the home. During this tour, the following was noted: LPA was toured through the interior of the home. This is a one-story home which consists of one (2) bedrooms, two (2) restrooms, living room, office and kitchen. LPA did not observe any hazards inside of the home. Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The applicant states that there are no poisons on the premises. The applicant was advised that any poisons must be locked with a key or combination lock. There is a first aid kit located in the home. There are smoke detectors throughout the home and a carbon monoxide detector in the homes hallway and office which applicant tested; LPA heard the alarm and found them to be operational.

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Justin Dorsey	TELEPHONE: (323) 558-2710
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

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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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: KHODAGULYAN FAMILY CHILD CARE	FACILITY NUMBER: 198020748
	VISIT DATE: 05/27/2021

NARRATIVE

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LPA Dorsey toured the outdoor space of the home. LPA Dorsey observed a fully fenced concrete play area with toys for children to play. While touring the yard LPA observed there were two gates in the backyard that could be opened leading outside of the home’s premises. LPA Dorsey observed that the gate handles were out of the reach of child. The outdoor area also has an “indoor playground”, this playground is set up as an indoor classroom in a detached building in the back yard. LPA Dorsey observed that this building had toys for the children to play and no hazardous items.

All areas identified on the facility sketch were inspected. Areas that are accessible to daycare children: one (1) bedroom, one (1) restroom, living room, backyard and “indoor indoor”. Off-limits/inaccessible to daycare children: one (1) bedroom, one (1) bathroom office, and kitchen.

**Rooms that are off-limits need to be made inaccessible during operating hours** The applicant/licensee does understand that licensing staff may have access to off-limit areas during inspection visit if necessary.

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Justin Dorsey	TELEPHONE: (323) 558-2710
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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: KHODAGULYAN FAMILY CHILD CARE	FACILITY NUMBER: 198020748
	VISIT DATE: 05/27/2021

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The following was discussed with the applicant/licensee:
· Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.
· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification, TB clearance, and a valid criminal record clearance associated to the facility license.
· A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.
· The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked and batteries replaced as needed.
· Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home
· Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Mandated reporter requirements was reviewed and explained.
· Fire and safety drills must be performed every six months and documented for review by the Department.
· Smoking is prohibited in a family child care home, 24/7.
· Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
· No baby bouncers, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.
· All adults living and working in the home shall be made of aware of the Departments right to inspection authority.

Infant Care: Applicant/ states that she does care for infants. LPA observed an infant crib located in the daycare room area. LPA advised the applicant/ to sleep infants where the infant can be directly supervised and advised against sleeping infants in a separate room. LPA reviewed safe sleeping practices. Infants should sleep mouth up, on their backs, free of clutter surrounding their sleeping space. Safe sleep concepts were discussed and provided.

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Justin Dorsey	TELEPHONE: (323) 558-2710
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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: KHODAGULYAN FAMILY CHILD CARE	FACILITY NUMBER: 198020748
	VISIT DATE: 05/27/2021

NARRATIVE

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Medication: 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

Per applicant, she plans to carry liability insurance or a bond in accordance with standard established by Family Child Care statue. Signed statements (LIC282) will be on children’s files. The law requires Family Child Care provider to carry liability insurance or bond in the amount of $300,000 annually or to maintain the signed statement in the facility file.

The applicant does have proof of Health and Safety training (completion date:12/12/2020), Pediatric First Aid and CPR (expires on 12/2022). The applicant/licensee has proof of immunization against influenza, pertussis, and measles. Applicant completed required mandated reporter training on 09/02/2020. Mandated reporter training must be completed every 2 years. www.mandatedreporterca.com

LPA will email Safe Sleep Concepts, Capacity Handout (Small & Large), and information regarding best practices to maintain safe and healthy environment during COVID-19 health crisis.

LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

Per applicant, there are no dual licenses at this address.

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Justin Dorsey	TELEPHONE: (323) 558-2710
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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: KHODAGULYAN FAMILY CHILD CARE	FACILITY NUMBER: 198020748
	VISIT DATE: 05/27/2021

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Corrections needed before license can be approved:
1.) Applicant will send LPA Dorsey a copy of the homes deed.
2.) Applicant will place a safety lock on the cabinet under the sink in the restroom.
3.) Applicant will send LPA Dorsey an updated facility sketch for the home and outdoor area. The facility sketch will show the updated off-limits room and measurements.
4.) Applicant will send LPA Dorsey a completed LIC 279 (current children) form.

A copy of this report and all other Licensing reports must be made available to the public for 3 years.

Exit interview was conducted with applicant Monika Khodagulyan, via tele-inspection. A copy of this report and appeal rights will be emailed with a read receipt and confirmation of receipt of email, which will act as the applicant's signature. Applicant/Licensee will also sign report and mail to the Department.

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Justin Dorsey	TELEPHONE: (323) 558-2710
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC809 (FAS) - (06/04)

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