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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700489
Report Date: 06/19/2021
Date Signed: 06/22/2021 09:09:31 AM

Document Has Been Signed on 06/22/2021 09:09 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:HAKHVERDYAN FAMILY CHILD CAREFACILITY NUMBER:
197700489
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
06/19/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Eva Hakhverdyan TIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA), Maddox met with with applicant, Eva Hakhverdyan for the purpose of conducting a Pre-licensing. Present during this inspection was applicant only. This is a single story home with 3 bedrooms and 2 bathrooms. LPA verified all adults in the home (applicant only) has a fingerprint clearances and exams for T.B. **There are no pools, spas or any other bodies of water observed on the premises. Child Care areas include 2 bedrooms, 1 bathroom, and the backyard. Off limit areas include the Master Bedroom (door will be locked during day care hours), and 1 bathroom. There is a trampoline in the backyard that will be used for licensee's biological son, the trampoline if off limits to day care children.

The kitchen and bathroom were toured and inspected for proper storage of chemicals, detergents, cleaning compounds, medications and sharp pointed objects, all items were made inaccessible to children. All unused electrical outlets are plugged and play equipment and toys are available. Applicant is aware that baby walkers, bouncer, or any similar equipment are prohibited in any licensed facility.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2021
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: HAKHVERDYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700489
VISIT DATE: 06/19/2021
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The applicant is reminded of the requirement to report and unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC 624B.

As a REMINDER: when your child(ren) turn 18 years of age, you MUST SUBMIT an updated LIC279, LIC 508 and TB Screen and have your child submit for LIVESCAN background clearance. This also applies to any adult PRIOR to them moving into the home or who currently lives in the home. Also, PRIOR to employment of any adult, you must submit the LIC508, TB screening and obtain a background clearance through LIVESCAN.

**Updated Safe Sleep information distributed during this inspection: Issued applicant the following: SIDS information and Shaken Baby Syndrome pamphlet – For more information on SIDS and Safe Sleep Environments, please visit:


California Department of Public Health – California SIDS Program: http://www.cdph.ca.gov/programs/SIDS/pages/default.aspx
AAP-Free Training: Reducing the Risk of SIDS in Early Education and Child Care: http://shop.aap.org/Reducing-the-Rick-of-SIDS-in-Early-Education-and-Child-Care
And Caring for our Children, Safe Sleep Practices and SIDS/Suffocation Risk Reduction: http://cfoc/nrckids/org/standardview/spccol/safe_sleep

LPA also printed out the updated Regulation 102425 Infant Safe Sleep and LIC 9227 (An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file).

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2021
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: HAKHVERDYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700489
VISIT DATE: 06/19/2021
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LPA has verified Applicant has current CPR and First Aid training (exp 3/2023). Per applicant, there are no weapons or firearms of any kind on the premises. The required smoke detector, and carbon monoxide devises were present and in operable condition.

******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 o 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. applicant provides IMS.

· Applicant can access forms on line at www.ccld.ca.gov .

Home was found to be incompliance with Title 22 Regulations, applicant has a size 1A-10-BC, applicant will purchase a size 2A 10 BC and send in pictures. Upon receipt, home will be in compliance with Title 22 Regulations.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2021
LIC809 (FAS) - (06/04)
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