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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494654
Report Date: 10/28/2024
Date Signed: 10/28/2024 03:36:50 PM

Document Has Been Signed on 10/28/2024 03:36 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:SIMONYAN FAMILY CHILD CAREFACILITY NUMBER:
197494654
ADMINISTRATOR/
DIRECTOR:		SIMONYAN, ARMINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 401-0272
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
10/28/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Armine Simonyan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Annual Random Visit Conducted In Armenian

Licensing Program Analyst (LPA) Silva Garibyan conducted a site visit for the purpose of a Required- 3 year visit. LPA met with the licensee and toured the home inside and outside at 12:00PM on 10/28/2024. Licensee was present with eight children and one assistant. The licensee's home is a single story 5 bedroom, 2 bathroom home with living/dining room and kitchen. Main care is provided in the living room and in four bedrooms. Children also have access to one of the bathrooms in the living/dining room. Off limit areas include Bedroom(2)/Office, kitchen, and Bathroom(2)/Laundry room. Parents enter the facility through the front gate and access the day care through the main entry door. There is no pool, spa or other bodies of water on the premises. LPA toured all areas used by children during this inspection. Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption. The bathroom and the kitchen was observed free of chemicals or toxic items that can pose danger to children in care. The outdoor play area was inspected. Children's outdoor play equipment and toys are age appropriate and in good repair. LPA observed the yard to be fully fenced. The Fire Extinguisher (2A-10-BC) is mounted on the wall in the living room (purchased on 11/13/2023). There is a working smoke/carbon monoxide detectors located in the kitchen. The First Aid kit was observed and complete. Page 1
SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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: SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494654
VISIT DATE: 10/28/2024
NARRATIVE
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 Licensees was unable to demonstrate current proof of CPR/First Aid Certificates ( expired 08/2024). Licensee did not have proof of renewal of the Mandated Reporter AB1207 training (completed on 08/11/2020). Licensee reports she has no firearms or weapons in the home.

Children play in the back yard. LPA observed the yard to be clean, free of debris, and fully fenced. The fire drills are done twice a year. Last drill was conducted on 10/14/2024. Licensees 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. Licensees stated that a cell phone with active service in the home will be the main contact number while children are in care.

LPA observed in the living room the Parent Board with all necessary posting required ( Facility License (LIC 203), Emergency Disaster Plan (LIC610A), Notification of Parents' Rights Poster (PUB 394), If You see Something Say Something poster. Child Care Facility Roster (LIC9040) was on file.

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, LIC702, LIC 995A/Parent's Rights, LIC995E/Caregiver Background Check, LIC 9150/Parent Notification, LIC 9212/Parent's Responsibilities, PM 286/Immunization Card.

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

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
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: SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494654
VISIT DATE: 10/28/2024
NARRATIVE
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A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

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.

No infants are enrolled at this time. LPA discussed the safe sleep regulations with licensees 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.
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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
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: SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494654
VISIT DATE: 10/28/2024
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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/.

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 Armine Simonyan informed that there are no Registered Sex Offenders living in the facility.

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

Exit interview conducted and report was reviewed with the licensee Armine Simonyan.

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

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2024 03:36 PM - It Cannot Be Edited


Created By: Silva Garibyan On 10/28/2024 at 01:58 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: SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494654

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in Mandated Reporter Training has not been completed and not readily available upon request (for licensee and assistant) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2024
Plan of Correction
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Per Licensee, proof of correction will be sent to LPA via email by 11/04/2024
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
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Based on record review, the licensee did not comply with the section cited above. Licensees was unable to demonstrate current proof of CPR/First Aid Certificates (expired on 8/09/2024), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2024
Plan of Correction
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Per Licensee, proof of correction will be sent to LPA via email by 11/04/2024
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:Betty Bell
LICENSING EVALUATOR NAME:Silva Garibyan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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