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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001557
Report Date: 02/04/2022
Date Signed: 02/04/2022 02:39:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MELIKYAN, GAYANEFACILITY NUMBER:
384001557
ADMINISTRATOR:MELIKYAN, GAYANEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 672-4935
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY:14CENSUS: 6DATE:
02/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gayane MelikyanTIME COMPLETED:
02:45 PM
NARRATIVE
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On February 4, 2022, Licensing Program Analyst (LPA), Van, conducted an unannounced annual inspection and met with Licensee Gayane Melikyan and a helper. The purpose of the inspection was explained and granted entry to the home by the Licensee. Licensee has six children in care, one infant, and five preschoolers. The Daycare area is on the ground level including, the playroom, nap room, bathroom, and backyard. The entire second floor and the garage are off-limit to children. Per Licensee, when a child shows signs of illness, the Licensee will separate and have the child waiting in the nap room while contacting the parent to pick up.

LPA and Licensee inspected the daycare areas for health and safety hazards during the inspection. LPA observed the following; The daycare area is clean, orderly, and equipped with safe, age-appropriate toys and equipment. The home has adequate lighting, ventilation and is free from defects or conditions that endanger children in care. The daycare has a working smoke alarm, carbon monoxide detector, and a fully charged fire extinguisher. First aid supplies are available for children. Poisons, detergents, cleaning compounds are inaccessible to children. The backyard is observed to be fenced, clean, and has age-appropriate toys and outdoor equipment are in good condition. LPA observed Infants have their individual cribs. LPA informed the Licensee not to have any pillows, toys, or anything hanging above the infants' cribs. The Licensee had posted all the required forms, such as facility License, Notification of Parent's Rights, and Notification of Personal Rights. Per Licensee, there are no firearms or weapons. The Licensee does have a cat. According to the Licensee, the cat always stays in the off-limit area on the second floor and is fully vaccinated.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MELIKYAN, GAYANE
FACILITY NUMBER: 384001557
VISIT DATE: 02/04/2022
NARRATIVE
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The Licensee states she provides breakfast, lunch, dinner, morning and afternoon snacks to children. The Licensee has a water pitcher and cups available for children. LPA observed no pools, spas, or other bodies of water on the premises. The Licensee states that the last fire drill was conducted last month, but the Licensee did not document or keep a log of the drill.

During the inspection, LPA reviewed all records of children and staff that were present. LPA observed each child has a complete emergency information card with the child's full name, telephone number, and location of a parent or other responsible adult to be contacted in an emergency; the name and telephone number of the child's physician, and the parent's authorization for the Licensee or registrant to consent to emergency medical care. During staff records review, LPA observed the Licensee has valid Pediatric FirstAid & CPR. However, the Licensee helper did not have any record maintained. Records such as FirstAid & CPR, immunization records, Mandated Reporter training were missing or not available for review. In addition, Criminal record clearance for this helper was not on file. As a result, the Title 22 deficiency was being cited, and a civil penalty of $500 was assessed today.

Licensee was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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 discussed the safe sleep regulations with Licensee 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 the Licensee 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.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MELIKYAN, GAYANE
FACILITY NUMBER: 384001557
VISIT DATE: 02/04/2022
NARRATIVE
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The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. LPA reviewed AB 1207 with the Licensee. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

LPA encouraged the Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

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.

An exit interview was conducted, and Plans of Corrections (POC) were developed and reviewed with Licensee. The Licensee is informed to provide a copy of the Evaluation Report and the Type "A" Deficiency cited to the parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 shall be maintained in all Children's files. A copy of this report and appeal rights were discussed and emailed to the Licensee, whose signature on this form confirms receipt of these reports. Notice of Site Visit will also be emailed to Licensee. Licensee was advised Notice of Site Visit to remain posted for 30 days.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MELIKYAN, GAYANE
FACILITY NUMBER: 384001557
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the Licensee did not comply with the section cited above as the Licensee helper did not have a criminal record clearance. The helper could not provide any document or ID to confirm the identity, which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 02/07/2022
Plan of Correction
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The Licensee must ensure that all employees and volunteers must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. Licensee states she will have the helper complete the fingerprint process by February 7.
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: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022
LIC809 (FAS) - (06/04)
Page: 4 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MELIKYAN, GAYANE
FACILITY NUMBER: 384001557
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

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 by not documenting or keeping a record of the drill, which poses/posed a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
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Licensee must document every drill conducted and keep records. Licensee plans to keep a notebook of all fire drills moving forward.
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: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022
LIC809 (FAS) - (06/04)
Page: 5 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MELIKYAN, GAYANE
FACILITY NUMBER: 384001557
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 by failing to ensure that all staff complete the mandated reporter training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
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Licensee states she will have the helper complete the mandated reporter training by February 18.
Section Cited
Personnel Records
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: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6