197700462-6-11-2021-12-CC-IORA-C3W95N-20210611230414

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197700462
Report Date: 05/28/2021
Date Signed: 06/11/2021 11:04:38 PM

Document Has Been Signed on 06/11/2021 11:04 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	YERITSYAN FAMILY CHILD CARE		FACILITY NUMBER:	197700462
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	05/28/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	07:20 PM
MET WITH:	Tatevik Yeritsyan		TIME COMPLETED:	08:30 PM

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 5/28/2021 at 7:00 p.m., Licensing Program Analysts (LPA) Isabel Ortega virtually conduct an announced prelicensing inspection for a Small Family Child Care Home. LPA was greeted by applicant, Tatevik Yeritsyan, who guided the LPA on a tour of the Family Child Care Home facility. The applicant will operate Monday through Friday: 7:30 a.m. to 5:00 p.m. The applicant will provide breakfast, snack, lunch, and dinner as needed. Applicant plans to enroll in a food nutrition program. This is a one-story family home which consists of four bedrooms, three bathrooms, a kitchen, dining room, living room, laundry room, den, and four sheds located in the back yard. The den and bedroom 4 will be the primary location in which care is provided. Children will use the bathroom located to the left of the hallway by the entrance of the home. The backyard is divided in two sections one will be utilized for outside play(shaded area observed) the other side will be off limits(LPA observed a gate separating the yards). The off-limit areas include bedroom #1, #2, and #3, the two restrooms, laundry room, the kitchen, dining room, living room, four sheds(key locked located in the back yard)and the second yard where the pool is located. The fire place is inaccessible to children. located in the off limits area. Cots will be made available for children to nap.

SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: YERITSYAN FAMILY CHILD CARE	FACILITY NUMBER: 197700462
	VISIT DATE: 05/28/2021

NARRATIVE

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The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and center air ventilation. The home has age appropriate toys, play equipment and materials. Applicant stores sharp knives, medications in an inaccessible top kitchen cabinet. Applicant has a complete First Aid Kit in the home, which is stored inaccessible to children. Cleaning solutions and supplies are stored underneath the sink(maintained locked), the kitchen opening has a child safety gate making the kitchen inaccessible to children.

Applicant was reminded she must ensure proper care and visual supervision is always provided at all times. The backyard is free of hazards, lose or sharp objects.

LPA observed a fire extinguisher (2A10BC) that meets the State Fire Marshal standards. Applicant tested the smoke detector and carbon monoxide detector at 7:35 p.m., and they were found to be in operable condition. Per the applicant, there are no weapons or firearms in the home, nor did LPA observe any weapons or firearms during the inspection.

The applicant's Pediatric CPR/First Aid expires on 3/8/23. the 8 hour Preventative Health and Safety class that includes child nutrition was completed on 06/01/2019. In addition application completed the Preventative Lead poisoning training on 4/16/202. The applicant had the required immunization against pertussis (Tdap), measles (MMR), and tuberculosis (TB). The Mandated Reporter training was completed on 5/26/2021.

SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: YERITSYAN FAMILY CHILD CARE	FACILITY NUMBER: 197700462
	VISIT DATE: 05/28/2021

NARRATIVE

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LPA observed a parent board and other Licensing required forms at the entrance of the home visible to parents.

The following was discussed with applicant:
Mandatory licensing forms for the children’s files, facility forms/records, and information to be posted in the family child care home; Requirements to conduct fire and disaster drills once every six months and record it; Role and responsibilities of being a mandated reporter were reviewed; Licensee was made aware that it is her responsibility to know the regulations as well as anyone who assists in providing care; Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified; Regulation prohibits the smoking of any kind in the family child care home.

The Licensee was informed that all adults living in or having access to the home, or employees are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Central Index prior to having contact or working with children. If the aforementioned is not adhered to, a Civil Penalty of up to $500, per non-cleared adult will be assessed immediately. Please advise your analyst of any person who will be visiting regularly or for longer than one week. The applicant was advised to utilize the Request for Live Scan Service form LIC9163 to have adults fingerprinted and associated to the home.

SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: YERITSYAN FAMILY CHILD CARE	FACILITY NUMBER: 197700462
	VISIT DATE: 05/28/2021

NARRATIVE

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The Applicant has been advised of the requirement to report Unusual Incidents continues as usual. A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above. The licensee was informed to continue to utilize the Unusual Incident Report/Injury Report form LIC624B when submitting the report to the department.

The Applicant was informed that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days whenever a licensing inspection is conducted. If a Type A deficiency is cited, a copy of the licensing report must also be posted for 30 days. The same report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and licensee must obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian and place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports (LIC 9224). If these requirements are not met civil penalties per violation will be assessed.

SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: YERITSYAN FAMILY CHILD CARE	FACILITY NUMBER: 197700462
	VISIT DATE: 05/28/2021

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Beginning on January 1, 2018, Assembly Bill 1207 (2015) 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. Applicants must meet requirements as a precondition to licensure. New employees shall have 90 days from date of employment to complete training as required. The training may be conducted at the following website www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

The licensee was advised to continue to visit the department's website to access licensing forms, Quarterly Updates and Provider Information Notices (PINs): www.ccld.ca.gov

Per Title 22 requirements applicant did not meet the pool regulations. The gate barricading the second yard, where the underground pool is located on the far left side of the yard is not meeting Title 22 regulation. The height length of the gate does meet Title 22 regulations measures 5 feet 2 inches. Once the pool gate is corrected and meets Title 22 regulation under Health and Safety code, applicant may continue with FCCH license application process. According to applicant she will correct gate separating the yards to meet Title 22 regulations and standards by the end of the week.

An exit interview was conducted, and a copy of this report, was provided via mail with all required licensing forms for child file.

SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC809 (FAS) - (06/04)

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