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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195700115
Report Date: 04/21/2025
Date Signed: 04/21/2025 12:52:50 PM

Document Has Been Signed on 04/21/2025 12:52 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:GRIGORYAN FAMILY CHILD CAREFACILITY NUMBER:
195700115
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
04/21/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:18 AM
MET WITH:Licensee Lusine GrigoryanTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 4/22/25 at 8:18am AM Licensing Program Analyst (LPA), Jeanine Lipsey conducted an unannounced Random Annual Inspection for a capacity increase. The fire clearance was conducted on 3/10/25. LPA was met by staff Fenik Kesoyan who did not speak English. LPA waited to till 8:30 to start the inspection when Licensee Lusine Grigoryan arrived. An Entrance checklist was provided to licensee. LPA observed 6 children in care being supervised by 2 staff. Capacity as specified on the license is being maintained. Days and hours of operation are Monday through Friday 6am to 12am. (LIC) 282- Affidavit Regarding Liability Insurance was observed in the children’s files.

LPA observed the following required postings: License, PUB 394 Notification of Parents’ Rights Poster, and LIC 9148 Earthquake Preparedness Checklist. LPA observed LIC610A Emergency Disaster Plan, the disaster/fire drill log was not completed, licensee stated she was told that it only had to be done for a large license. LPA advised all LIC9213 Notice of Site Visits shall be posted for 30 days after each site visit. LPA advised, any licensing report documenting a Type A citation must be posted for 30 days.

LPA toured the home inside and outside. The Applicant's home is a single story, 3-bedroom, 2-bathroom home with living room, kitchen, and laundry room (inside the kitchen). The attached garage is now a living area with a separate address and separate entry from the street. There is no access to the other living area from inside of the house. The main entry door will be used to enter the facility. Bedroom #2 & #3 and the bathroom #2 and laundry room, are off limits to the children in care. These areas are made off limits with locked doors and will remain locked while children present. LPA observed all doors to be locked. Children will eat in the living room and sleep Bedroom #1 and use the bathroom in bedroom #1.

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NAME OF LICENSING PROGRAM MANAGER: Betty Bell
NAME OF LICENSING PROGRAM ANALYST: Jeanine Lipsey
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2025
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/21/2025 12:52 PM - It Cannot Be Edited


Created By: Jeanine Lipsey On 04/21/2025 at 10:51 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GRIGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700115

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(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: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the licensee did not comply with the section cited above in that Licensee does not have proof of purchase date of the fire extinguisher which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Licensee will purchase a new fire extinguisher and send phto proof.
Type B
Section Cited
CCR
102417(g)(9)(A)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record the licensee did not comply with the section cited above in that No fire drills are being conducted or documented which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Licensee will preform a drill and send photo proof when the first drill is completed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Betty Bell
NAME OF LICENSING PROGRAM MANAGER:
Jeanine Lipsey
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/21/2025 12:52 PM - It Cannot Be Edited


Created By: Jeanine Lipsey On 04/21/2025 at 10:51 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GRIGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700115

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview andrecord review, the licensee did not comply with the section cited above in that there no record of 15 minute checks for 2 infants which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Licensee will send proof of 15 minutes checks being conducted.
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.
Betty Bell
NAME OF LICENSING PROGRAM MANAGER:
Jeanine Lipsey
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
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: GRIGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700115
VISIT DATE: 04/21/2025
NARRATIVE
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Fireplace in the living room is properly screened rendering it inaccessible to children in care. Licensee provide meals and snacks. LPA discuss food preparation, storage and ensuring a log and information regarding dietary restrictions and allergies are kept up to date. Licensee states at this time no children have allergies. Licensee stated that a cell phone with active service in the home will be the main contact number while children are in care.

LPA did not observe any poisons resent during the inspection. Detergents, cleaning compounds, medication and other hazardous item were made inaccessible to children. Per applicant, there are no firearms, weapons. LPA observed the home to be free from defects or conditions which may endanger the children. LPA observed the kitchen cabinets and drawers to not have any hazards that can endanger the children.

LPA observed fully stocked first aid kit. LPA Lipsey observed a working carbon monoxide/smoke detector in all the bedrooms and living room, LPA was able to hear a successful test. Fire extinguisher was observed and located in the kitchen but was not serviced since purchased. Electrical outlets were observed to be inaccessible to children in care with installed child proof outlets. The home was observed to be clean and orderly with heating and ventilation. LPA observed safe toys, play equipment, and materials.

LPA observed the outdoor area to be fenced and free from hazards LPA observed multiple play equipment in good repair. Licensee ensures that children in care are always supervised. LPA did not observe bodies of water on the premises.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunizations Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, and documentation of 15-minute Infant Sleep Check (0-24 months). 15 minute checks were not being documented.



Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunizations against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate. Licensee’s pediatric CPR/First Aid was completed on 3/17/25. Mandated Reporter Training Completed on 1/13/25. Due to both staff first language is Armenian, they do not have Mandated Reporter Training. Page 2 of 4
NAME OF LICENSING PROGRAM MANAGER: Betty Bell
NAME OF LICENSING PROGRAM ANALYST: Jeanine Lipsey
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC809 (FAS) - (06/04)
Page: 7 of 7
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: GRIGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700115
VISIT DATE: 04/21/2025
NARRATIVE
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On this date, 4/14/23 the California Attorney General - Megan's Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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-and­resources/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.

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: https://www.ada.gov/resources/child-care-centers/

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NAME OF LICENSING PROGRAM MANAGER: Betty Bell
NAME OF LICENSING PROGRAM ANALYST: Jeanine Lipsey
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: GRIGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700115
VISIT DATE: 04/21/2025
NARRATIVE
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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Based on LPA's observations, the following deficiencies listed on the attached LIC809D (deficiency page) are being cited in accordance with Title 22, Division 12, Chapter 3, of the California Code of Regulations. Deficiencies that are being cited need to be cleared to protect the children's health & safety.

The following corrections need to be completed by 5/8/25. Photo proof will be sent to LPA via email.

1. Fire drills need to be completed.

2. 15-minute checks to be completed for 2 infants.

3. The fire extinguisher needs to be serviced or newly purchased

Exit interview conducted and report was reviewed with the Licensee Lusine Grigoryan. A notice of site visit was given and advised Licensee that it must remain posted for 30 days.

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NAME OF LICENSING PROGRAM MANAGER: Betty Bell
NAME OF LICENSING PROGRAM ANALYST: Jeanine Lipsey
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC809 (FAS) - (06/04)
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