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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197402404
Report Date: 07/29/2021
Date Signed: 08/04/2021 09:33:09 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2021 and conducted by Evaluator Antonio Almanza
COMPLAINT CONTROL NUMBER: 30-CC-20210301120030
FACILITY NAME:ONEGENERATIONFACILITY NUMBER:
197402404
ADMINISTRATOR:VARDANYAN, KRISTINEFACILITY TYPE:
830
ADDRESS:17400 VICTORY BLVD.TELEPHONE:
(818) 708-6377
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:60CENSUS: DATE:
07/29/2021
UNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Kristine VardanyanTIME COMPLETED:
12:51 PM
ALLEGATION(S):
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Allegation - Day care infant's feeding plan is not being followed.

****Amended Document
INVESTIGATION FINDINGS:
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On July 29, 2021 at 12:27 am, Licensing Program Analyst (LPA) Antonio Almanza, conducted an unannounced site visit for the purpose of delivering an Amended finding for complaint received on March 1, 2021. LPA met with Kristine Vardanyan, Director, and explained the purpose of the visit.
During the Complaint (Control # 30-CC-20210301120030) investigation, interviews were conducted, and observations were made regarding the allegation. Day care infant's feeding plan is not being followed based on available information which revealed the facility did not adhere to Title 22 Regulations. The facility is not discarding the Formula from partially consumed bottles at the end of each day.

Based on LPAs observation, interviews conducted, and records reviewed the preponderance of evidence standard has been met per management, therefore the above allegation is found to be SUBSTANTIATED according to the California Code of Regulations, Title 22, Division 12, Chapter 1, Section 101427(j)(1), are being cited on the attached LIC9099D. A copy of this report, Appeal Rights, and Notice of Site Visit were explained and provided to the Director Kristine Vardanyan.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 30-CC-20210301120030
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ONEGENERATION
FACILITY NUMBER: 197402404
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2021
Section Cited
CCR
101427(j)(1)
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101427 Infant Care Food Service, (j) (1) Formula in a partially consumed bottle shall be discarded at the end of each day.



This Requirement is not met as evidenced by:
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Director will provide written statement of how the facility will ensure that all food in a partially consumed bottles shall be discarded at the end of each day. Director will provide Personnel roster and signatures from all staff informing them of the change.
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Based on observation, interview and record review, The Licensee is not discarding the Formula from partially consumed bottles at the end of each day, which poses an [immediate or potential] Health [and or] Safety, [and or] personal rights risk to persons in care.
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Director will provide verificaion by 08/03/2021.
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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.
SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2