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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198004693
Report Date: 10/17/2024
Date Signed: 10/17/2024 12:10:47 PM

Document Has Been Signed on 10/17/2024 12:10 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:ST. GREGORY'S A & M HOVSEPIAN CHILD CARE CTR, INC.FACILITY NUMBER:
198004693
ADMINISTRATOR/
DIRECTOR:		ARPY JAHJAHFACILITY TYPE:
850
ADDRESS:2215 E. COLORADO BLVD.TELEPHONE:
(626) 578-1343
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 88TOTAL ENROLLED CHILDREN: 88CENSUS: 71DATE:
10/17/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Maro Shahinian - DirectorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Nolan Tcheng and Mariah Aguirre conducted an unannounced Annual inspection. Upon arrival at 8:35am, LPA met with Director Maro Shahinian. At 8:45am,LPAs were led on a tour of the facility. This is a Preschool program with a Toddler Option, which consists of 7 classrooms (1 of 7 is a Toddler Room). Per licensee, there are currently 76 enrolled in the program. Hours of operation for this facility are 7:50am-3pm for school hours and 3-5:30pm for extended care.

Licensing staff observed all required forms/publications to be posted in the office. Snack menus were reviewed to ensure that they are being posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days are available upon request.

At 8:45am, LPAs entered and inspected Blue A (3s): 13 children with 2 staff members, Blue B (3s): 13 children with 2 staff members, Red A (2s): 7 children with 2 staff members, Red B (2s): 9 children with 1 staff member, Green A (Pre-K): 11 children with 2 staff members, Green B (Pre-K): 8 children with 2 staff members, and Yellow (Toddler Option): 10 children with 2 staff members. Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were inaccessible to children. Furniture and equipment are in good condition, free of sharp, loose, or pointed parts. All floors are clean and safe.

All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair. Trash cans used to discard food have tight fitting lids. The facility was observed to be free of flies, other insects and rodents. Sufficient individual storage space for children was observed and each child has a cubby. Drinking water was readily available indoors. At this time, the office is used as an isolation area. A cushioned area is available for an ill child to rest on. First Aid supplies are available and complete. Facility has a functioning carbon monoxide detector that meets statutory requirements. Director states there are no weapons, firearms, or bodies of water on the premises.

At 9am, Napping equipment was observed in the classrooms. There were stacked cots with linens/bedding individually wrapped.


REPORT CONTINUES PAGE 1 of 4
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: ST. GREGORY'S A & M HOVSEPIAN CHILD CARE CTR, INC.
FACILITY NUMBER: 198004693
VISIT DATE: 10/17/2024
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At 9:10am, a fire extinguisher was observed. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 06/05/024, as indicated on service tag. Per State Fire Marshall standards, fire extinguishers shall be serviced annually. Center has an in line sprinkler and smoke/carbon monoxide detector that was unable to be tested during the inspection.

There are four restrooms available for children in care. A restroom is present in Blue A that both Blue A, B, and Red A share. There are two restrooms in the hallways that Green A, B, and Red B share. Toddler room has there own toilet and sink available for children who are potty trained. All toilets, hand washing, and bathing facilities are safe, sanitary and are operating properly.

All food preparation areas and food storage areas are kept clean and are free of litter, rubbish and rodents and/or any other vermin. Snacks were reviewed for availability, quantity and appropriateness to children in care. This facility provides AM snack, Lunch, and PM snack.

Toddler room was observed to be physically separated from the other classrooms. There is the in-room restroom available. There is a changing table available in the classroom as well. LPA observed the diaper changing table to be at least one inch thick, with raised sides of at least 3-inches, and within arms reach of the sink. The outdoor play area is directly accessible from the Yellow Room and per director, is only for use by the Toddler class.

At 9:25am, LPAs reviewed the outdoor play area. Outdoor playground equipment is in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment, slides, and similar equipment are cushioned with material that absorbs a fall. There is one outside space called Slide are with a play structure, small slide, play houses carts, climbing wall, and bikes. There is another space called Bikes/Lego that has a bike path, play houses, slides, carts, sensory bins, and climbing apparatus. The Toddler yard has age appropriate climbing equipment, benches, play houses, small slide, and bikes. Drinking water is readily available outdoors.

Teacher-child ratios were observed to be in accordance with Title 22 regulations. Staff names were recorded. All children were observed to be under visual supervision of a teacher during tour. The Licensee is within the conditions, limitations, and capacity specified on the license. All areas were identified on the Facility Sketch were inspected.

REPORT CONTINUES PAGE 2 of 4

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
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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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: ST. GREGORY'S A & M HOVSEPIAN CHILD CARE CTR, INC.
FACILITY NUMBER: 198004693
VISIT DATE: 10/17/2024
NARRATIVE
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At 9:50am, facility records were reviewed. Sign in and out sheets were reviewed to ensure that the person who signs the child in and out uses their full legal signature and records the time of the day. Disaster drills have been conducted at least every six months. Staff files were reviewed for a health screening report and immunizations that meet regulatory requirements. LPAs observed that 5 of 7 staff files were missing immunization records. LPA discussed with director the importance of having Measles, Pertussis, and Influenza records for all staff. Criminal Record Clearance for adults and verification of CPR/First Aid and health preventative practices documentation was reviewed. The name of the child care center director or fully qualified teacher(s) designated to act in the director's absence is on file. Educational background, training, and/or experience for each staff present are on file and were reviewed. During the education background review, LPA observed that 2 of 7 staff were missing transcripts or proof of educational units in their files. LPAs explained that that proof of educational background should be kept file. LPAs also observed that all staff files did not have current proof of completion of Mandated Reporter Child Care Provider (AB1207) training. LPA explained that the training must be done every two years. A random sample of Children’s Records were reviewed to ensure that they are complete.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

Facility Representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed 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. REPORT CONTINUES PAGE 3 of 4

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
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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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: ST. GREGORY'S A & M HOVSEPIAN CHILD CARE CTR, INC.
FACILITY NUMBER: 198004693
VISIT DATE: 10/17/2024
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Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Facility Representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

The deficiencies listed on the following pages were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809D for deficiencies that are being cited and need to be cleared to protect the children’s health & safety.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Director Maro Shahinian, at 12pm. Plan of corrections were developed and Copy of Report provided.

END OF REPORT PAGE 4 of 4

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 10/17/2024 12:10 PM - It Cannot Be Edited


Created By: Nolan Tcheng On 10/17/2024 at 11:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ST. GREGORY'S A & M HOVSEPIAN CHILD CARE CTR, INC.
FACILITY NUMBER: 198004693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in all Staff Files reviewed did not have a current Mandated Reporter Child Care Provider (AB1207) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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Per Director, they will have all staff complete Mandated Reporter Child Care Provider (AB1207) and seubmit proof to LPA by POC date.
Type B
Section Cited
CCR
101217(a)(6)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (6) Documentation of the educational background, training and/or experience specified in this chapter.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in 5 of 7 Staff Files, Staff #1 & 4, were missing educational units, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Per Director, Staff #1 & Staff #4 will enroll in the courses they are missing. Proof of enrollment will be submitted to LPA by POC of date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ana Chico
LICENSING EVALUATOR NAME:Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


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Created By: Nolan Tcheng On 10/17/2024 at 11:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ST. GREGORY'S A & M HOVSEPIAN CHILD CARE CTR, INC.
FACILITY NUMBER: 198004693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995
(c) The day care center shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person’s personnel record that is maintained by the day care center.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in 5 of 7 staff files were missing immunization records,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2024
Plan of Correction
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Per Director, they will have Staff #1-2 & 4-6 submit immunization records by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ana Chico
LICENSING EVALUATOR NAME:Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


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