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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494654
Report Date: 08/31/2021
Date Signed: 08/31/2021 02:48:35 PM

Document Has Been Signed on 08/31/2021 02:48 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:SIMONYAN FAMILY CHILD CAREFACILITY NUMBER:
197494654
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 9DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Armine SimonyanTIME COMPLETED:
03:10 PM
NARRATIVE
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On 08/31/2021 at 12:51 pm, Licensing Program Analyst (LPA) Antonio Almanza, conducted an unannounced Annual Required Inspection and was met by Licensee, Armine Simnoyan. Days and hours of operation are Monday to Friday 7:30am – 5:30 pm. Upon arrival there were 9 children in care, Licensee contacted the parent of Child 1 and Child was picked up at 1:02 pm.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed and Licensee confirmed that the kitchen, bathroom in main home, and office are off limits. All other rooms and areas in the home are accessible to children in care. There are no firearms or ammunition 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, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (323) 401-0256.

There are currently no infants in care. LPA discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan (LIC9227) is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping. Pg 1.

SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2021
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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494654
VISIT DATE: 08/31/2021
NARRATIVE
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Licensee does not properly ensure that children in care are supervised at all times; LPA observed Licensee standing in front of the home while 2 children where inside the main home and 8 children sleeping in the back building. Licensee is aware 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 play area in the backyard is fenced . There are 2 citrus fruit trees that have low hanging branches with thrones. During today’s visit Capacity as specified on the license is not being maintained. LPA reviewed a sample of children’s files and observed files were incomplete. Licensee’s Mandated Reporter Training was completed prior to Licensure on 09/11/20. Licensee’s pediatric CPR/First Aid expires on 07/24/2022. 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. Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following Two Type A Deficiencies are being cited: 102416.5 Staffing Ratio and Capacity and 102417 Operation of a Family Child Care Home(see next page, 809 D). Licensee was Issued 2 Type B deficiencies (see next page, 809 D)

Upon receipt of a Type A violation, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A copy of LIC 9224 was given to licensee.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days. Appeal Rights provided. Pg 2.

SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Antonio Almanza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/31/2021 02:48 PM - It Cannot Be Edited


Created By: Antonio Almanza On 08/31/2021 at 01:32 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: 08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2021
Section Cited
CCR
102416.5(a)

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102416.5 Staffing Ratio and Capacity (a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This Requirement is not met as evidenced by:
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Licensee had child 1 picked up by his mother. Licensee will provide written statement acknowledging that she understands her Licensed capacity and will maintain it.
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Based on observation, interview and record review, The Licensee did not adhere to her Licensed capacity, LPA observed 9 children in care, which poses an immediate Health and Safety, and personal rights risk to persons in care.
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Type A
09/01/2021
Section Cited
CCR102417(a)

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102417 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.
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Licensee will write written statement acknowledging that she will adhere to Regulations and provide supervision to children in care at all times by having all children in the same building at all times.
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Based on observation, interview and record review, The Licensee did not ensure children in care are supervised at all times, LPA observed 7 children sleeping in the back building unsupervised and 2 children inside the main home unsupervised, which poses an immediate Health and Safety, and personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Mary Ruiz
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/31/2021 02:48 PM - It Cannot Be Edited


Created By: Antonio Almanza On 08/31/2021 at 02:06 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: 08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2021
Section Cited
CCR
102421(b)

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102421 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:
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LIcensee will complete the files for children enrolled in the FCCH by Tuesday 09/07/2021.
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Based on observation, interview and record review, The Licensee does not have emergency information for 9 children enrolled , which poses an [immediate or potential] Health [and or] Safety, [and or] personal rights risk to persons in care.
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Type B
09/03/2021
Section Cited
CCR102417(g)(8)

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102417 Operation of a Family Child Care Home (g)(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:
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Licensee will complete facility Roster for all children enrolled in FCCH and provide a copy to the Regional Office by 09/03/2021
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Based on observation, interview and record review, The Licensee does not have a facility roster for 9 children enrolled , which poses an [immediate or potential] Health [and or] Safety, [and or] personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Mary Ruiz
LICENSING EVALUATOR NAME:Antonio Almanza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2021


LIC809 (FAS) - (06/04)
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