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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195700583
Report Date: 07/03/2025
Date Signed: 07/03/2025 12:36:18 PM

Document Has Been Signed on 07/03/2025 12:36 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:AVETISYAN FAMILY CHILD CAREFACILITY NUMBER:
195700583
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/03/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:08 AM
MET WITH:Vahagn AvetisyanTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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On 7/3/25 Licensing Program Analyst (LPA) Jeanine Lipsey met with applicant Vahagn Avetisyan. The purpose of the visit was, announce a pre-license visit to ensure that health, safety, and personal rights as required by Title 22 and Health and Safety Regulations governing California Child Care Homes will be met. Entrance check list was provided. This is an application for a small Family Child Care Home. The applicants spouse and 2 adult children were also present. Applicants are requesting a capacity of eight children, ages 1-13 years. The Family Child Care Home will operate Monday – Friday 7am-10pm. Applicant stated that a cell phone, with active service in the home will be the main contact number while children are in care. Applicant preferred language is Armenian.

Because the applicant rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

LPA discussed the LIC282 Affidavit Regarding Liability Insurance with applicant. If applicant does not have insurance this form needs to be filled out and put in the child folder.

LPA reviewed with applicants, 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. LPA Lipsey observed the following required postings: LIC 610A Emergency Disaster Plan, PUB 394 Notification of Parents’ Rights Poster, and LIC 9148 Earthquake Preparedness Checklist. LPA advised, once licensed, the facility license shall be posted. LPA advised all LIC 9213 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 advised a fire/disaster drill log shall be available and performed at least every six months. Page 1 of 5

NAME OF LICENSING PROGRAM MANAGER: Betty Bell
NAME OF LICENSING PROGRAM ANALYST: Jeanine Lipsey
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2025
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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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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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: AVETISYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700583
VISIT DATE: 07/03/2025
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The applicant has completed preventive health and safety/Childhood Nutrition/ Lead Exposure Prevention on 3/23/25 and Mandated Reporter training completed on 3/25/25 The applicant has current pediatric CPR/First Aid training completed on 6/16/25.

Applicant guided LPA on a tour of the home. All areas identified on the home sketch were inspected, including but not limited to off limit areas. Per applicant off limit areas will be in inaccessible. This home consists of 3 bedrooms, 2 bathrooms, living/dining room, kitchen and outside laundry area. Per applicant, the children will use the following areas: Livingroom, bedroom #3 and bathroom #1

The bedrooms #1, #2, bathrooms # 2 and laundry area) is off limits to the children in care. A safety gate is installed to make the kitchen dining room and bedroom # 2 inaccessible. Bedroom #1 is inaccessible via a safely locked door. Kitchen cabinets and drawers, the stove, refrigerator, sink and counter space area were observed. The bathroom, with working toilet and sink, was observed to be free of hazards and good repair.

The living room was observed to have children-sized tables, chairs, toys and a variety of age-appropriate materials. There were no fixtures, furniture, and equipment that have been banned or recalled by the United States Consumer Product Safety Commission. LPA observed a fully stocked first aid kit in the kitchen. The provider will supply and cook for the children. The LPA observed the home was clean and orderly, with heating and ventilation for safety and comfort. Per applicant, children will eat in the Living room and sleep in bedroom #3. LPA observed applicant test the carbon monoxide/smoke detectors in the Living room, Dining room, and all bedrooms, they were in good working condition. LPA observed a fire extinguisher (2A10BC) in the dining room with the purchase date of 5/23/25. LPA advised the fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries should be replaced. LPA observed there were no defects or conditions which might endanger the children. All electrical outlets in the home were covered. The LPA observed there were no poisons, detergents, cleaning compounds, medicines, and other items which could pose a danger, accessible to children. Per applicant, there are no weapons or firearms of any kind in the facility currently. The LPA did not observe any weapons.

Cots were observed for napping. LPA advised, there should be one crib or play yard for each infant who is unable to climb out of the crib or play yard. LPA observed the home to have a play yard. LPA advised, the applicant the placement of cribs or play yards shall not hinder entrance or exit to and from the space where infants are sleeping and the doors shall remain open. page 2 of 5

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

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6
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: AVETISYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700583
VISIT DATE: 07/03/2025
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LPA advised, mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged. Mattresses shall be made specifically for the size crib or play yard in which they are placed.

LPA advised, cribs or play yards shall be free from all loose articles, objects, bumper pads shall not be used, and there shall be no objects hanging above or attached to the side of the crib. Per Health and Safety Code Sections 1596.846(b) and (c), LPA advised, baby walkers, bouncers, Johnny jumpers, trampolines, and saucer chairs are not permitted.

LPA discussed when a child shows signs of illness, he/she shall be separated from other children until the nature of the illness is determined. If it is a communicable disease, he/she shall be separated from other children until the infectious stage is over. The Isolation area will be located in the dining room.

Children will utilize the front yard to play. Outdoor play area was observed to be fenced, and Per applicant, when children are having outside time, they will ensure 100% supervision and never leave children unattended. LPA toured the backyard and observed an in-ground pool next to the back house which has a separate address of 6927 Bellaire Ave. The back house and pool area have children’s safety gates on home page to prevent entry into the back area.

LPA toured the backyard area to ensure that the pool fencing meets Title 22 requirements. LPA observed the pool’s metal gate to be 5 feet high, with a self-latching gate door that swings into the pool. The applicant will have the door fixed to swing away from the pool. The self-latching device is located 3 inches from the top of the gate door. The metal gate encloses the pool on one and half side. The other sides are enclosed by the property wall which measures 6 feet, and the back house. The spacing between railings is 4 inches. The distance between the ground and the bottom of the fence is 2 inches from the hard surface(concrete). LPA observed a 17-inch life ring with a US Coast Guard Approval label and LPA was able to hear the pool alarm sound when the water was disturbed. LPA took photos to document in the file. Per applicant the 12-inch pole and body hook is on order. There are no other bodies of water on the premises. Applicant was advised to watch videos regarding pool safety from our website, https://ccld.childcarevideos.org/.

LPA discussed, the applicant shall be present in the home and shall ensure that children in care and always supervised. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility provides care per day. page 3 of 5

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

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: AVETISYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700583
VISIT DATE: 07/03/2025
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Applicant 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, 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.

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) or (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.

On 5/22/25, 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.

LPA discussed, Smoking is prohibited on the premises of a family childcare home as specified in Health and Safety Code Section 1596.795(a). A baby walker shall not be allowed on the premises of a family childcare home in accordance with Health and Safety Code Sections 1596.846(b) and (c).

Applicants were informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.



page 4 of 5
NAME OF LICENSING PROGRAM MANAGER: Betty Bell
NAME OF LICENSING PROGRAM ANALYST: Jeanine Lipsey
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: AVETISYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700583
VISIT DATE: 07/03/2025
NARRATIVE
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LPA discussed the safe sleep regulations with applicant 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 applicant, 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.

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 platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

The following items need to be in place before a license will be considered. Corrections are due by 8/4/25.

1. The gate does not swing away from the pool.

2. Need 12 feet pole with body hook.

Exit interview conducted, and report was reviewed with Applicant Vahagn Avetisyan.



Page 5 of 5
NAME OF LICENSING PROGRAM MANAGER: Betty Bell
NAME OF LICENSING PROGRAM ANALYST: Jeanine Lipsey
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC809 (FAS) - (06/04)
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