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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700498
Report Date: 11/03/2021
Date Signed: 11/03/2021 12:52:23 PM

Document Has Been Signed on 11/03/2021 12:52 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:GRIGORYAN FAMILY CHILD CAREFACILITY NUMBER:
197700498
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
11/03/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Susanna GrigoryanTIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Liana Stepanyan and Lady King-Lewis conducted a Pre licensing Inspection with Applicant Susanna Grigoryan, who guided analysts on a tour of the home. This is a one-story home 3-bedroom, 3-bathroom, kitchen, living room and dining area. Separate structure for day care area with bathroom and car port with storage structure and outside play area. There is no pool/spa on the premises. Family members residing in the home include 3 adults (Applicant and 2 adults’ spouse and mother in law and 2 minor children son (3 year old) and daughter (5 year old). All adults living/residing in the home are fingerprint cleared and associated.

Application Documents: The Applicant stated the facility days and hours of operation will be Monday through Friday 7:30 to 6:00pm serving children ages 0-13.



Facility Sketch shows the daycare will take place in separate structure behind the home near car port. The daycare will take place in the entire structure which includes 1 bathroom and side yard play area. The entire home, storage structure, and rear yard is off limits.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Liana Stepanyan
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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: GRIGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700498
VISIT DATE: 11/03/2021
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LPAs discuss Health Section 1596.846(b) and (c)–102417 (g)(10) and provided applicant with a visual copy of prohibited items. LPAs did not observe prohibited items during the inspection. There is a designated area for ill child(ren) is near front entry of daycare area. Applicant stated no guns or weapons in the home LPAs did not observe any guns or weapons during today inspection. Applicant aware ammunition must be stored in a separate lock box from weapon/firearms. Facility sketch complete showing the off-limit areas. Applicant will be using a cell phone for daycare use. Applicant is aware cell phone shall always be available during day cares hours and charged. LPA observe a fully charge 2A10BC fire extinguisher in the daycare area near the entrance during the inspection. Applicant made poisons, medication, and cleaning items inaccessible to children kept in off limit area of home. LPAs advised applicant she is allowed to keep cleaning items in the daycare area bathroom in a secure area with a lock.

Kitchen: The kitchen is off limit area for the children. Applicant plans to supervise children and have helper bring the food to the daycare area or vise versa.

Bathroom accessible to children: The following are inaccessible: shampoos, mouthwash, medication, perfumes, razor, air freshener, nail polish and polish remover. LPAs observed a clean, safe and operable Toilet and faucet. Applicant is aware paper towels shall be available for children use. LPA went over COVID-19 protocols.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Liana Stepanyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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: GRIGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700498
VISIT DATE: 11/03/2021
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LPAs also informed Applicant 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 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 per day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Documents Provided and or Discussed: The following were provided to comply with Title 22 requirements: Fire Drill Log, roster, Safe Sleep poster, water lead poster, required postings and list of required CCL forms for each child in care. Applicant states she does not have liability insurance at this time.



Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

Incidental Medical Services (IMS) policy was discussed, informing applicant when any IMS is provided, a plan for providing IMS must be submitted to the Department prior to providing care to a child that need IMS. The plan shall state the type of IMS the facility will be offering, stating the person providing care has been trained, provide the name of the IMS. The plan will also provide the steps that will be taken when IMS is provided to a child.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Liana Stepanyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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: GRIGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700498
VISIT DATE: 11/03/2021
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The following information regarding ADA was discuss and the following information 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

Applicant was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within 24 hours of incident by telephone and in writing within 7 day of incident to the department. Applicant was informed all suspected Child Abuse should be reported to the Child Abuse Hot-line at 1-800-540-4000. The above incident should be report on the form LIC624B per the regulation. The form should be email to unusualincidentreport@dss.ca.gov

Physical Plant: LPAs observed the structure daycare area to be clean and orderly, central air and heating, age appropriate toys and play equipment, and working smoke detector and carbon monoxide. Applicant inform smoking is prohibited; applicant stated no one smokes in the home.

Outdoor: LPAs observed the play area to be safe and free of hazards. The play area is free from garden tools, poisonous plants, thorn trees, cactus, or lawn mower all inaccessible to children. Play area is fenced and gated all around, no body of water on the premises. LPAs did not observe any pets in the home. Applicant is aware to report to licensing whenever there is a change in the home.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Liana Stepanyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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: GRIGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700498
VISIT DATE: 11/03/2021
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Advisory/Other: LPA observed a first Aid kit with emergency supplies and a thermometer. Applicant’s CPR/First Aid expire 04/01/2023. Preventative Health & Safety completed 10/08/21. Electrical outlets are inaccessible to children. Children will nap in play pen and on cots with blankets.

Applicant aware no infant shall be swaddled, and car seat shall not be used for sleeping. Applicant is aware to supervise infants while they are sleeping by physically checking every 15 minutes and documenting the child status. Applicant should refer to regulation 102425(J) for documentation requirement. If the infant’s Individual Infant Sleeping Plan [LIC 9227 (3/20)] does not have Section C completed, the provider shall return the infant to their back for sleeping. LPAs discussed the safe sleep regulations with Applicant and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.

The following shall be done prior to licensure: Paint chipping on the front door of the daycare area and parent board with required posting.

An exit interview was conducted, the report was reviewed with applicant Susanna Grigoryan, and a copy of the report and appeal rights were provided.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Liana Stepanyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5