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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195700115
Report Date: 06/14/2023
Date Signed: 06/14/2023 12:14:17 PM

Document Has Been Signed on 06/14/2023 12:14 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:GIRGORYAN FAMILY CHILD CAREFACILITY NUMBER:
195700115
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
06/14/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Lusine Grigoryan, ApplicantTIME COMPLETED:
12:30 PM
NARRATIVE
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On 06/09/2023 at 8:50 AM Licensing Program Analyst (LPA) Silva Garibyan conducted an announced visit for the purpose of a Pre-licensing inspection with Lusine Grigoryan, applicant. Applicant was informed that we are going to tour the home for a pre-licensing requirement per Title 22 regulations and health and safety standard code requirements. The licensee is applying for a Small Family Child Care Home license for a maximum capacity of 8 children. Per the application, at this time, the ages the applicant wishes to provide services for are children newborns through 13 years old with the hours of Monday- Friday from 6:00 a.m. to 12:00 a.m. Licensee was informed that any changes to ages, hours and days of operation shall be submitted to the department for approval prior to initiation of changes. Landlord Consent and copy of current rental agreement is on file. Applicant has no pets. Applicant has submitted a disaster plan. The applicant has completed preventive health and safety/Childhood Nutrition/ Lead Exposure Prevention and Mandated Reporter training (completed on 05/23/2023). The applicant has current pediatric CPR/First Aid training completed on 03/20/2023. Family members residing in the home include applicant and applicant's two children ( 10 years old and 9 years old). Applicant was informed that her children under 10 years of age, count in her capacity whenever they are present.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GIRGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700115
VISIT DATE: 06/14/2023
NARRATIVE
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Applicant's home is a single story, 3 bedroom, 2 bathroom home with living/dining room, kitchen, laundry room (inside the kitchen), attached garage. The main entry door will be used to enter the facility. The kitchen, laundry room, and the garage are off limits to the children in care. Safety gate is installed to make the kitchen inaccessible. There is no access to the garage from inside of the house. Children will eat and sleep in the living/dining room and Bedroom 1/Day Care Room. Fireplace in the living/dining room is properly screened

LPA observed a parent board in the day care room. Licensee has the following documents posted in the FCCH; Facility License (LIC 203), Notification of Parents' Rights Poster (PUB 394) , Child Care Facility Roster (LIC9040), Emergency Disaster Plan (LIC610a), Lead Poisoning Facts/Potential Sources Of Lead/Effects Of Lead Exposure. A review of the children's records was conducted and are found to have the following: LIC 282 Affidavit Liability Insurance, LIC 627/Consent for Medical Treatment, LIC 700/ID and Emergency Information, LIC 995A/Parent's Rights, LIC995E/Caregiver Background Check, LIC 9150/Parent Notification, LIC 9212/Parent's Responsibilities, PM 286/Immunization Card.

The Day-care room was observed to have children size tables and chairs and a variety of age appropriate materials. LPA observed children’s books, blocks and wooden play kitchen. LPA observed napping cots, and emergency water and first aid kit ( in the laundry room). LPA observed applicant test the carbon monoxide and smoke detector in the hall way. LPA observed a fire extinguisher mounted in the kitchen. All electrical outlets in the home were covered. Page 2 of 5

SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GIRGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700115
VISIT DATE: 06/14/2023
NARRATIVE
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Bedrooms and the bathrooms were inspected. The bathrooms were observed to be free of hazards.

All bottom cabinets and drawers in the kitchen were observed to have safety latch. Stove was observed to have children’s safety latches making them inaccessible to the children in care.

Home will access the backyard through the living/dining room. Backyard is enclosed with a fence. The yard was observed to have age appropriate toys. No bodies of water were observed in the home. Applicant confirmed NO fire arms or weapons are in the home. Applicant is stating that when children are having outside time he will ensure 100% supervision and never leave children unattended.

Facility Administration: Licensee completed training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. Pediatric A certificate of completion of a course or courses in preventive health practices as defined in s subdivision (a) or certified copies of transcripts that identify the number of hours and the specific course or courses taken for training. (8 hours required) Preventative Health and Safety practices including childhood nutrition/Lead Exposure Prevention are completed and placed in facility file.

Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GIRGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700115
VISIT DATE: 06/14/2023
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LPA discussed the safe sleep regulations with [applicant, licensee, or facility representative] 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 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.

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS:

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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 reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GIRGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700115
VISIT DATE: 06/14/2023
NARRATIVE
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To receive important license related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview was conducted with licensee Lusine Grigoryan. The licensing determination of this application will be reviewed with Licensing Program Manager for final resolution

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
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