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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495164
Report Date: 10/28/2022
Date Signed: 10/28/2022 12:11:33 PM

Document Has Been Signed on 10/28/2022 12:11 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:MANUKYAN FAMILY CHILD CAREFACILITY NUMBER:
197495164
ADMINISTRATOR:LUSINE MANUKYANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 392-0730
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
10/28/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Lusine ManukyanTIME COMPLETED:
12:03 PM
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On October 28, 2022, Licensing Program Analyst (LPA) Doris Whitmore conducted an announced inspection with applicant Luisine Manukyan for the purpose of a pre-licensing inspection change of location& Capacity change 17343 Covello Street, Lake Balboa, CA 91406. The facility has a completed 850 Fire Inspection Report.The purpose of this inspection is to ensure the standards for a Family Child Care Home are being met in accordance to California Title 22 Regulations and California Health and Safety Codes. LPA met applicant Luisine Manukyan who guided a tour of the inside and outside of the home. Currently living in the home is Applicant’s husband and two adult children. At the time of the Pre- Licensing was only applicant’s son.

The applicant is applying for a Large family childcare license with a max of 14. Control of Property Deed currently is on file. Per the application, currently the ages the applicant wishes to provide services to children are 4 to 13-year-olds and the hours of operation are Monday- Friday from 6:00a.m. to 7:00p.m. Applicant was informed that any changes to ages, hours, days of operation shall be submitted to the department for approval prior. Documents posted on the Parent Board were the Emergency Disaster Plan Facility Sketch, Earthquake Preparedness, & Notification of Parents Rights. Parents will access the home through the main front door.

The areas identified on the facility sketch were inspected. The home is a one story, 3 bedrooms, 2 bathrooms home with a kitchen, livingroom, dining room, patio, & pool. The Main Day Care will be provided in the living room. The off-limits areas of the home are the kitchen in doors, stove outdoors, 2 other bedrooms, pool, storage, & bathroom. In the Living room where the main day care will be provided LPA observed a couch, tv which was mounted high, a fireplace which had a white gate which was well mounted to the wall. In the Livingroom on the shelves were materials such as, crayons, markers, books, puzzles, games, globe easel, dry erase board. To the left is the dining room with a white table and four chairs. From the dining room is the kitchen which was observed to have a safety lock to prevent access. In the Kitchen is a door that leads to the side of the house and remains locked. Page 1

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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 6
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: MANUKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495164
VISIT DATE: 10/28/2022
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Next to the kitchen is Master Bedroom that will only be used if there is a child that is sick. Bedroom# 2 is the son’s bedroom that is off limits and have a safety lock on the door. Bedroom #3 is the daughter’s bedroom. All bedrooms were observed and did not have any items observed to have items risk to children in care. Both bathrooms were observed, and the bathroom did not have any toxins, medications, or chemicals that would pose a risk to the children.In-between the two bedrooms were a closet LPA observed in the closet to have towels, blankets, & emergency food. There are no weapons in the home, LPA did not observe any weapons at the time of inspection.

The home was inspected for safety, comfort, cleanliness, telephone services, heating ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. The home was inspected for safety, comfort.

The home was equipped with a fully charge fire extinguisher, which is a 2-A:10-B:C The home is also equipped with a smoke detector and carbon monoxide detector both were tested. There is a fully equipped first aid kit in the home. LPA observed backyard area. Backyard has a patio with a stove, refrigerator, small wooden kitchen. White safety locks were on the kitchen drawers to prevent access. There is a swimming pool on premises. Swimming pool is fenced per regulation. Once the gate is open LPA observed that the gate does not swing away from the pool, self-close or self-latch.

Applicant was made aware of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on childcare licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541


Email Address: childcareadvocatesprogram@dss.ca.gov
Immunizations: Commencing September 1, 2016, SB 792, prohibits a person from being employed or volunteering at a childcare facility or family day care if he or she has not been immunized against influenza, pertussis and measles. LPA discussed the influenza waiver during the inspection.

Mandated Reporter Training: Beginning on January 1, 2018, AB 1207, requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. Website: www.mandatedreporterca.com. Page 2
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: MANUKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495164
VISIT DATE: 10/28/2022
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Licensee was reminded of their responsibility to report suspected child abuse.

Mandatory Forms for the children’s files and provider’s files were discussed. Applicant was referred to LIC 311D: Records To Keep in Your Family Child Care.

FORMS TO BE POSTED


LIC203 Facility License
LIC 610A Emergency Disaster Plan
LIC 9148 Earthquake Preparedness Checklist
PUB394 Notification of Parents Rights Poster
Children’s Records Requirements:
LIC 700 Identification and Emergency Information
LIC 627 Consent for Emergency Medical Treatment
LIC 282 Affidavit Regarding Liability Insurance
LIC 9150 Parent Notification Additional Children in Care
LIC 9166 Consent/Verification for Nebulizer Care
CDPH 286 (Immunization Blue Card) with Immunization record
PUB 72- Family Child Care Consumer Guide
LIC 995A Notification of Parent’s Rights
LIC 995E Caregiver Background Check Process
LIC 9212 Family Child Care Consumer Awareness Information
PM 286 California School Immunization Record (blue card)-http://www.dhs.ca.gov/publications/forms/immunization.htm
LIC 9224 Acknowledgement of Receipt of Licensing Report, if applicable.
Facility Records:
LIC 624B Unusual Incident/Injury Report
LIC 9040 Child Care Facility Roster
LIC 9052 Employee Rights,
LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
LIC 9149 Landlord Consent Form, if you plan to care for more than 6 for Small or 12 for Large
LIC 9151 Property Owner/Landlord Notification Form
Personnel Records as required in Tittle 22, Division 12, Chapter 3, Section 102416.1, including but not limited to proof of current pediatric CPR and First Aid Certificates, Preventative Health certificate and criminal record information.
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SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: MANUKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495164
VISIT DATE: 10/28/2022
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Proof of immunizations against pertussis (TDAP), measles (MMR), and influenza
Mandated Reporter certificate – www.mandated reporterca.com – renewed every two years.
Licensee was made reminded that it is the licensee’s, as well as anyone who assists in providing care responsibility to know the regulations. Licensee was also encouraged to read the Child Care quarterly updates every season as they come out to stay informed of any changes or updates to statutes and regulations.

Applicant was advised that regulation prohibits the smoking of tobacco in a private residence licensed as a family childcare home during the hours of operation.



Applicant was made aware that state law prohibits baby walkers, bouncy seats, exer-saucers and any other items that fall into that category. Applicant was also reminded that only children who are eating may be in highchairs and that car seats are utilized only for transportation.

LPA discussed the safe sleep regulations with applicant [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

Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep

LPA also informed applicant [facility representative] 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.

This facility plans not to provide Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 4

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: MANUKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495164
VISIT DATE: 10/28/2022
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Applicant was also informed that the provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome.

· Applicant was reminded that all adults 18 and over living or working in the home, 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.


· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.

· A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.

· Annual fees must be paid promptly and by the due date or a late fee shall be assessed, and/or the License shall be terminated. (If paying by check please make sure to write facility number on check to ensure that payment is applied to your facility number)

· The fire extinguisher must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries should be replaced.

· Changes should be reported the to the Department as soon as they occur such as construction and remodeling, telephone number changes and/or if you move from home.

· Reporting requirements: Applicant must report any unusual incident or injuries to the Child Care Regional office by telephone within 24 hours and in writing within 7 days. Applicant was provided with LIC 624 as a reference.

·Fire and safety drills must be performed every six months and documented for review by the Department.

· All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

· LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov Page 5

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: MANUKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495164
VISIT DATE: 10/28/2022
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Prior to licensure the following will need to be corrected:

Add safety locks to the middle of the outdoor stove and lower bottom

Correct the latch on the upper part of the gate around the pool to ensure that the gate swings away from the pool, self-close and self-latch

Remove Plastic Wrap on top of counter

Outlet next to refrigerator remove green extension cord or place higher.

Cover Screws that are protruding, presently a potential hazard if children are playing and run into it causing an injury

Remove Curtain higher on pole

Safety locks on closet doors

safety locks on closet doors

Outdoor Area Safety Gate to prevent access on side of house that leads to kitchen backdoor

Exit interview was conducted, and the report was emailed to applicant due to equipment difficulties. The applicant will have until 11/11/2022. to submit all corrections needed.

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SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6