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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495072
Report Date: 04/05/2022
Date Signed: 04/05/2022 10:00:34 AM

Document Has Been Signed on 04/05/2022 10:00 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:SARGSYAN FAMILY CHILD CAREFACILITY NUMBER:
197495072
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
04/05/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
07:20 AM
MET WITH:Hermine Sargsyan/ApplicantTIME COMPLETED:
10:10 AM
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
On 04/05/2022 at 07:20 AM Licensing Program Analyst (LPA) Silva Garibyan conducted an announced visit for the purpose of a Pre-licensing inspection with Hermine Sargsyan, Applicant. Applicant was informed that we are going to tour the home for a pre-licensing requirement per title 22 regulations and health and safety standard code requirements. Applicant is applying for a small day-care of a capacity of 8. Hours of operation for the facility will be 7:00 AM- 6:00 PM Monday- Friday and will be closed all major holidays. Ages served are new born - School age. Applicant has submitted a disaster plan. The applicant has completed preventive health and safety/Childhood Nutrition/ Lead Exposure Prevention and Mandated Reporter training ( completed on 04/05/22). The applicant has current pediatric CPR/First Aid training that will expire in February of 2024. There is no pool, spa or other bodies of water on the premises. Family members residing in the home include the applicant and applicant's minor daughter. Applicant states there are no firearms or weapons of any kind in the facility at this time. Interior: This is a single story dwelling with two bedrooms, one bathroom, kitchen , living/dining room. This is the back house on the property. The front unit on the property has different address and occupied by the owners (the address for the front unit: 6048 Denny Ave, North Hollywood, CA 91606).The home was inspected inside and out for safety, comfort, cleanliness, telephone service (cell phone operating at all times), heating and ventilation, poisons, detergents/cleaning compounds, medication and hazardous items that can pose a danger to children are kept in latched cabinets inaccessible during operating hours.

Page 1 of 4

SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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 4
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: SARGSYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495072
VISIT DATE: 04/05/2022
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
On limits: Living/dining room, bedrooms, kitchen, and bathroom. Living/dining room is where the main care will be provided. Children will be provided with meals and snack in the main care area. Nap time will be provided in Bedroom#2. LPA observed adequate supply of soap and poster guidance of effective hand washing procedures during COVID-19 provided next to sink. 1 operable toilet, sink and no immediate or potential hazards.

LPA observed latches on all cabinets and drawers. Sharp items are kept in the latched drawer. Bedrooms all inspected and no immediate hazards observed.

The outdoor area/back yard is fenced in. Licensee is stating that when children are having outside time she will ensure 100% supervision and never leave children unattended. LPA observed a storage shed in the back yard. The shed is observed to be locked.

Licensee was provided a Self-Assessment guide to follow in response to COVID-19 and was also informed that during today’s inspection that Licensing Program Analyst, Garibyan provided Technical Assistance in response to reducing the spread of COVID-19. Applicant was informed to follow CDC guidelines and stay up to date with the Provider Information Notices while using best practices during the COVID-19 Pandemic.

Fire extinguisher (2A-10-BC) is located in the living room. Applicant has an operable Smoke and Carbon Monoxide detectors located in all rooms. An accessible First Aid Kit equipped with, cleansing pads healing ointment, bandages, gauze, and a digital thermometer in closet of entrance of home.

Page 2 of 4

SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: SARGSYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495072
VISIT DATE: 04/05/2022
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
Facility Administration: Licensee completed training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. Pediatric A certificate of completion of a course or courses in preventive health practices as defined in s subdivision (a) or certified copies of transcripts that identify the number of hours and the specific course or courses taken for training. (8 hours required) Preventative Health and Safety practices including childhood nutrition/Lead Exposure Prevention are completed and placed in facility file.

Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with [applicant, licensee, or facility representative] 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 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.

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS:

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: http://www.ada.gov/childqanda.htm Page 3 of 4

SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: SARGSYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495072
VISIT DATE: 04/05/2022
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 reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with the Applicant, Hermine Sargsyan.

Page 4 of 4

SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Silva Garibyan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4