<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419778
Report Date: 08/08/2024
Date Signed: 08/08/2024 04:34:04 PM

Document Has Been Signed on 08/08/2024 04:34 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:AGSHEHIRLYAN FAMILY CHILD CAREFACILITY NUMBER:
197419778
ADMINISTRATOR/
DIRECTOR:		KARINE AGSHEHIRLYANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 448-6767
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91601
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
08/08/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Rena Babikyan, Assistant TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA) Lilia Hernandez conducted an unannounced annual required inspection to the above facility on 08/08/2024. LPA arrived at the facility at 8:45AM, identified self and met with Rena Babikyan, Assistant #1. Assistant disclosed to LPA Licensee was not present today due to illness. Assistant #1 guided analyst on a tour of the facility. LPA provided Licensee with a copy of the LIC 126 Entrance Checklist to help facilitate the inspection.

LPA observed 1 infant, 8 children, Assistant #1, and Assistant #2 present upon arrival.
Capacity as specified on the license is being maintained.

At 9:06AM, Assistant #1 contacted Karine Agshehirlyan, Licensee, via telephone to notify Licensee that LPA was present to conduct an inspection. Assistant #1 place the Licensee on speaker and Licensee disclosed to LPA that she became ill the evening of 08/07/2024. Licensee disclosed that she did not report her illness and did not close the facility today, 08/08/2024, because she did not want to inconvenience the parents. Licensee planned to have 3 Assistants present in her absence. Licensee disclosed to LPA that she will not be returning to her place of residence and will be staying at a relative’s home for the duration of the day, which exceeded the 20 percent temporary absence allowed.

LPA reminded licensee that Section 102417(a) Operation of a Family Child Care Home states the licensee shall be present in the home and shall ensure that children in care are supervised at all times. 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 is providing care per day.

---Page 1 of 5
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Lilia Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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 11
Document Has Been Signed on 08/08/2024 04:34 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Lilia Hernandez On 08/08/2024 at 01:36 PM
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: AGSHEHIRLYAN FAMILY CHILD CARE
FACILITY NUMBER: 197419778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Type A
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. 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 is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interviews, the licensee did not comply with the section cited above in Licensee disclosed to LPA that she became ill the evening of 08/07/2024. Licensee disclosed that she did not report her illness and did not close the facility today, 08/08/2024, because she did not want to inconvenience the parents. Licensee planned to have 3 Assistants present in her absence. Licensee disclosed to LPA that she will not be returning to her place of residence and will be staying at a relative’s home for the duration of the day, which exceeded the 20 percent temporary absence allowed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
1
2
3
4
Licensee shall ensure that temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day immediately.
Under Appeal
Type A
Section Cited
CCR
102370(k)
Criminal Record Clearance
(k) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees, volunteers that require fingerprinting and non-client adults residing in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in Emma Melikyan was not associated to Agshehirlyan Family Child Care prior to initial presence in the licensed Family Child Care Home which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
1
2
3
4
Licensee will ensure 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 immediately.
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:Rita Ramos
LICENSING EVALUATOR NAME:Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 08/08/2024 04:34 PM - It Cannot Be Edited


Created By: Lilia Hernandez On 08/08/2024 at 01:36 PM
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: AGSHEHIRLYAN FAMILY CHILD CARE
FACILITY NUMBER: 197419778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPA observed 3 smoke alarms in the home that were tested and operable. LPA was not able to verify if smoke alarms installed were also carbon monoxide detectors which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee will ensure that one or more carbon monoxide detectors will be installed in the facility, submit proof of purchase, photos of installation to LPA by POC due date.
Type B
Section Cited
CCR
102417(g)(9)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in LPA observed an LIC610A that did not include temporary relocation sites. (photo taken) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee will ensure the LIC610A is complete with temporary relocation sites that are public locations. A copy of the completed LIC610A will be submitted to LPA via email by POC due date.
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:Rita Ramos
LICENSING EVALUATOR NAME:Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 08/08/2024 04:34 PM - It Cannot Be Edited


Created By: Lilia Hernandez On 08/08/2024 at 01:36 PM
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: AGSHEHIRLYAN FAMILY CHILD CARE
FACILITY NUMBER: 197419778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in LPA observed Assistant #1 to have an expired First Aid CPR Certificate on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
1
2
3
4
Licensee will ensure that Assistant #1 has a current and valid First Aid CPR Certificate on file from an approved training center. (American Red Cross, American Heart Association, EMSA approved vendor). A copy of the current and valid First Aid CPR Certificate will be submitted via email to LPA by POC due date.
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in LPA observed Assistant #1 and Assistant #2 missing a completed LIC9052 Employee Rights form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee will ensure a completed LIC9052 Employee Rights form is in Assistant #1 and Assistant #2 file. A copy of the completed LIC9052 Employee Rights form will be submitted via email to LPA by POC due date.
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:Rita Ramos
LICENSING EVALUATOR NAME:Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 08/08/2024 04:34 PM - It Cannot Be Edited


Created By: Lilia Hernandez On 08/08/2024 at 01:36 PM
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: AGSHEHIRLYAN FAMILY CHILD CARE
FACILITY NUMBER: 197419778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.2(a)(2)
Reporting Requirements
(a) The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). (2) Any change in household composition including adults moving in or out of the home and anyone living in the home who reaches his or her 18th birthday.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above in Licensee did not report that Licensee is the only adult that resides in the home. Licensee’s husband and son no longer live in the home which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
1
2
3
4
Licensee shall ensure to adhere to reporting requirements immediately.
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in the Licensee did not provide the Department an updated Facility Sketch that identifies the changes reported with labels such as the kitchen, bath, living room, etc., no areas identified as “off limits” to children, door and window exits from the rooms were not shown in case of an emergency, and room sizes were not documented which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee will ensure that an updated Facility Sketch with all required details be submitted via email to LPA by POC due date.
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:Rita Ramos
LICENSING EVALUATOR NAME:Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 08/08/2024 04:34 PM - It Cannot Be Edited


Created By: Lilia Hernandez On 08/08/2024 at 01:36 PM
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: AGSHEHIRLYAN FAMILY CHILD CARE
FACILITY NUMBER: 197419778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in LPA observed Assistant #1 missing influenza which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
1
2
3
4
Licensee will ensure Assistant #1 has influenza vaccination or waiver on file. Licensee will submit proof of influenza vaccination or waiver via email to LPA by POC due date.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in LPA observed 1 of 5 children's records, Child #5, to have an LIC700 missing the name and telephone number of the child's physician/dentist information in case of emergency which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee will ensure all LIC700 forms in the children's records are complete. Licensee will submit corrections to Child #5 LIC700 form via email to LPA by POC due date.
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:Rita Ramos
LICENSING EVALUATOR NAME:Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 08/08/2024 04:34 PM - It Cannot Be Edited


Created By: Lilia Hernandez On 08/08/2024 at 01:36 PM
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: AGSHEHIRLYAN FAMILY CHILD CARE
FACILITY NUMBER: 197419778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in LPA observed facility roster missing parents/guardian complete names listed, and children who have left with out dates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee will ensure facility roster is complete and kept up to date. Licensee will submit an updated facility roster via email to LPA by POC due date.
Type B
Section Cited
CCR
102425(c)(1)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This plan shall be signed and dated by the infant’s authorized representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in LPA observed 1 of 5 Children's records, Child #3, to have an LIC9227 Infant Sleep Plan missing signatures and dates of authorized representative which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee will ensure all LIC9227 Infant Sleep Plans are signed and dated by the authorized representative. Licensee will submit Child #3 completed form via email to LPA by POC due date.
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:Rita Ramos
LICENSING EVALUATOR NAME:Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
Page: 7 of 11
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: AGSHEHIRLYAN FAMILY CHILD CARE
FACILITY NUMBER: 197419778
VISIT DATE: 08/08/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
At 9:30AM, LPA observed an individual identified as Emma Melikyan, arrived at the facility. Melikyan was the 3rd Assistant schedule to work today in the absence of the Licensee. Upon asking for identification, Melikyan was not on the Guardian Employee Roster. Assistant #1 provided LPA with a Department of Justice letter dated 05/21/2024 to show Melikyan had her fingerprints taken.

At 10:10AM, LPA contacted the Department, and it was confirmed that Melikyan was not associated to Agshehirlyan Family Child Care.

Assistant #1 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.

Facility operation hours are Monday to Friday from 8:00AM to 5:30PM.

The family child care home is located on a property with two homes. The family child care home is located on the back of the property and can be access through a driveway. This is a one-story home with 2 bedrooms, 1 bathroom, living room, kitchen, and an office upon entry to the home. The home also has a detached garage on the property.
Facility Sketch posted was missing room labels such as the kitchen, bath, living room, etc., no areas identified as “off limits” to children, door and window exits from the rooms were not shown in case of an emergency, and room sizes were not documented. (photo taken)

Assistant #1 confirmed that 2 bedrooms, 1 bathroom and living room are used for providing care and are accessible to children. LPA observed the home to be set up as a child care center. LPA observed a sofa and a 62x73 ½ closet with clothing stored as evidence that the home is a residence. Per Assistant #1, the Kitchen and detached garage are off-limits. The garage was made inaccessible by a door that remains locked. The kitchen has a door that reminds closed when not in used.
---Page 2 of 5
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 8 of 11
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: AGSHEHIRLYAN FAMILY CHILD CARE
FACILITY NUMBER: 197419778
VISIT DATE: 08/08/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA asked Assistant #1 who lives in the home. Assistant #1 did not know. Assistant #1 called Licensee via telephone and Licensee disclosed to LPA that she is the only adult that resides in the home. Licensee’s husband and son no longer live in the home. Licensee stated she did not report the change in household because she did not know she had to report personal information.

LPA reminded Licensee that as part of her reporting requirements, any change in household composition including adults moving in or out of the home and anyone living in the home who reaches his or her 18th birthday.

Per Assistant #1, there is no firearm on the premises. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

There is a working fire extinguisher that was serviced on 04/01/2024. LPA observed 3 smoke alarms in the home that were tested and operable. LPA was not able to verify if smoke alarms installed were also carbon monoxide detectors. LPA observed adequate heating and ventilation for safety and comfort.

There is currently 1 infant in care.

LPA discussed the safe sleep regulations with Assistant #1 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 observed 1 of 5 Children's records, Child #3, to have an LIC9227 Infant Sleep Plan missing signatures and dates of authorized representative.

LPA also informed Assistant #1 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. Licensee disclosed that infant equipment is replaced yearly.
---Page 3 of 5
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 9 of 11
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: AGSHEHIRLYAN FAMILY CHILD CARE
FACILITY NUMBER: 197419778
VISIT DATE: 08/08/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Assistant #1 was reminded that children in care are to be supervised at all times and made aware that children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children.

The outdoor area accessible to children is the back and side of the home. All other outdoor areas are inaccessible by a gate with a lock. LPAs observed no swimming pool or other bodies of water on the premises.

LPA reviewed a sample of children’s files and observed 1 of 5 children's records, Child #5, to have an LIC700 missing the name and telephone number of the child's physician/dentist information in case of emergency.

LPA observed facility roster missing parents/guardian complete names listed, and children who have left without dates.

Last documented fire/disaster drill was on 06/12/2024. LPA observed an LIC610A that did not include temporary relocation sites. (photo taken)

Licensee’s Mandated Reporter Training was completed on 01/31/2024. Licensee’s pediatric CPR/First Aid expires in October 2025.

LPA reviewed Staff records. LPA observed Assistant #1 missing influenza and to have an expired First Aid CPR Certificate on file. LPA observed Assistant #1 and Assistant #2 missing a completed LIC9052 Employee Rights form.

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/.

---Page 4 of 5
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 10 of 11
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: AGSHEHIRLYAN FAMILY CHILD CARE
FACILITY NUMBER: 197419778
VISIT DATE: 08/08/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Assistant #1 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.

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.

Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent.

LPA provided the facility with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit.

During the exit interview, Assistant #1, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Rena Babikyan, Assistant.
---Page 5 of 5
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 11 of 11