197494694-12-17-2021-30-CC-DMIA-C9SR85-20211217114723

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494694
Report Date: 12/17/2021
Date Signed: 12/17/2021 11:47:29 AM

Document Has Been Signed on 12/17/2021 11:47 AM - 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:	MIRZOYAN FAMILY CHILD CARE		FACILITY NUMBER:	197494694
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 1	DATE:	12/17/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Lusine Mirzoyan, Licensee and Nare Gervogyan, Licensee's daughter		TIME COMPLETED:	11:50 AM

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On 12/17/2021 8:10AM, Licensing Program Analyst (LPA), Denise Miranda, conducted an unannounced Annual Required Inspection and LPA met with Licensee, Lusine Mirzoyan and her daughter Nare Gevorgyan. Days and hours of operation are Monday-Monday 24hours. During this inspection, Licensee provided an updated form LIC279 (application form for a FCCH).

LPA observed all required documents to be posted, posted in a publicly accessible area at facility. LPA toured the home inside and outside and observed 01 child present at this time. LPA toured the home inside and outside and a census was taken. Licensee was provided a facility check list (LIC 126).

During this inspection it was reviewed that sketch does not match with the floor plan and yard of the facility. The following it was observed: off limit area - Bedrooms #1, #2 & #3 and Bathroom#2, and made inaccessible by use of door knob safety cover and the kitchen area are off-limit by use a safety children gate to separate the living room to the kitchen area, per licensee all backyard is off limit to the children in care.

LPA observed a house in construction located on the backyard of the premises. Per licensee the new construction area it was her detached garage that it was demolished it. Also, observed on the backyard area has a basement that it was not included on the sketch floor plan and yard, per licensee the basement area it is off-limit. All the backyard area is off limit and no children were observed during this inspection on this area. There is no swimming pool or other bodies of water on the premises.

The on-limit area are: dining room, living room, bathroom#1 and the driveway converted in playground area.

There are no firearms or ammunition on the premises. All poisons are kept in a locked

SUPERVISORS NAME: Peter Flores
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

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: MIRZOYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494694
	VISIT DATE: 12/17/2021

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storage area. 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 (Central air) 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 (818) 448-5247.

There are currently no infants enrolled in care. Per licensee and application form (LIC279), Licensee served age group from 1 year old to 12 years old. LPA discussed Safe Sleep Regulations with licensee ensures that children in care are supervised at all times and 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 backside of the house is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training, licensee was unable to provide copy of mandated reporter certification. Licensee’s pediatric CPR/First Aid expired on 08/2023. Per Licensee, no staff/volunteer is working now. All adults who reside in the home have a criminal record clearance or exemption.

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.

Staff interview conducted and documented at 10:20AM.

Exit interview conducted and copy of this report was provided to Licensee.

SUPERVISORS NAME: Peter Flores
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/17/2021 11:47 AM - It Cannot Be Edited

Created By: Denise Miranda On 12/17/2021 at 11:05 AM

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: MIRZOYAN FAMILY CHILD CARE	FACILITY NUMBER: 197494694
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416.3(a)

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: 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. It was observed during inspection, a new house in construction located on the back of the house (off-limit), licensee did not report to RO, which poses a potential health, safety to persons in care.
	POC Due Date: 12/24/2021
	Plan of Correction
1 2 3 4	Licensee agreed to provide LIC624, with revised sketch floor plan and yard along with documents of the new construction such as permit and other documents..

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Peter Flores

LICENSING EVALUATOR NAME:

Denise Miranda

LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC809 (FAS) - (06/04)

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