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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198012716
Report Date: 06/16/2022
Date Signed: 06/16/2022 02:58:58 PM

Document Has Been Signed on 06/16/2022 02:58 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:KOSTANDYAN FAMILY CHILD CAREFACILITY NUMBER:
198012716
ADMINISTRATOR:KOSTANDYAN, KARINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 665-7713
CITY:LOS ANGELESSTATE: CAZIP CODE:
90029
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 7DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Karine Kostandyan - LicenseeTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steven Tung conducted an unannounced annual inspection. A risk assessment was conducted prior to entering the facility. Due to COVID- 19 precautionary measures were taken, licensing staff present during inspection wore appropriate personal protective equipment. LPA met with Licensee Karine Kostandyan who guided analysts on a tour of the facility. The licensee's assistant was also present. There were 7 children present. Licensee states that there are currently 13 children enrolled.

There is 1 adult family member residing in the home (criminal record clearance on file). This is a one-story home which consists of 3 bedrooms, 2 bathrooms, a kitchen, a dining area, a living room, a converted garage/ADU, front yard (fenced) and backyard (fenced). The children use the bathroom next to the dining area, the dining area, the living room, the bedroom that is to the left of the Dining Area and below the kitchen (when looking at the facility sketch), the bedroom to the right of the kitchen, the driveway, and the front yard. LPA observed a staircase in the kitchen that leads down to a basement. The basement is made inaccessible and stores decoration supplies. Per licensee, areas off limits to children and parents include: the kitchen, the bedroom next to the entrance, the back yard, and the converted garage/ADU. The LPA toured all areas used by children during this visit.

Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for safety and comfort. There were safe toys, play equipment and materials observed for children. There is a working telephone service maintained in the home. At 12:11PM, LPA observed shampoos and body wash that were accessible to the children in the shower stall of the bathroom the children use. LPA also observed shaving razors in the mirror cabinet that were accessible to children in the bathroom the children use. Licensee states that there are no poisons in the home. The licensee does understand that poison must be locked with a key or combination lock.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Steven Tung
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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
Document Has Been Signed on 06/16/2022 02:58 PM - It Cannot Be Edited


Created By: Steven Tung On 06/16/2022 at 02:06 PM
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: KOSTANDYAN FAMILY CHILD CARE
FACILITY NUMBER: 198012716

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as evidenced by the shampoos and body wash that were accessible to children in the shower stall and shaving razors that were accessible to children in the mirror cabinet of the bathroom the children use which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2022
Plan of Correction
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Licensee will either install a child safety latch or remove all items from the mirror cabinet and the shower stall and will send a photo as proof to LPA via email by POC Due Date.
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, the licensee did not comply with the section cited above in 1 out of 2 staff records reviewed was missing current proof of mandated reporter training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2022
Plan of Correction
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Licensee will have Assistant take the mandated reporter training and provide proof of completion to LPA via email by the POC Due 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:Brandi VanOosten
LICENSING EVALUATOR NAME:Steven Tung
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/16/2022 02:58 PM - It Cannot Be Edited


Created By: Steven Tung On 06/16/2022 at 02:06 PM
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: KOSTANDYAN FAMILY CHILD CARE
FACILITY NUMBER: 198012716

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home 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 family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 staff records reviewed was missing MMR and Tdap immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2022
Plan of Correction
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Licensee will have Assistant provide immunization records of MMR and Tdap and send the proof to LPA via email by POC due 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:Brandi VanOosten
LICENSING EVALUATOR NAME:Steven Tung
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


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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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KOSTANDYAN FAMILY CHILD CARE
FACILITY NUMBER: 198012716
VISIT DATE: 06/16/2022
NARRATIVE
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LPA discussed the safe sleep regulations with licensee 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 as an additional resource. LPA also informed licensee 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.

Per licensee, there are no weapons, firearms or bodies of water on the premises. Children’s records were reviewed to ensure that each child has an Identification and Emergency form. There was 1 child’s record that was missing a LIC 995A form. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was last serviced 6/30/2021. The licensee has current Pediatric First Aid and CPR, which will expire 6/6/2023.

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

SB792 (Immunization Requirements for Staff and Employees) was discussed with the Licensee. The Licensee does have immunization documentation, but the Licensee’s Assistant does not have complete immunization documentation for review.

AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers Licensee completed training on 6/7/2021.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Steven Tung
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KOSTANDYAN FAMILY CHILD CARE
FACILITY NUMBER: 198012716
VISIT DATE: 06/16/2022
NARRATIVE
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Licensee 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.

· The Licensee shall be present in the home and shall ensure that children are supervised at all times.
· Children shall not be left in park vehicles.
· The capacity specified on the license shall be the maximum number of children for whom care can be provided.
· Car seats shall only be used for transportation purposes and shall not be used for sleeping.
· All children in care have the right to receive safe, healthful, and comfortable accommodations, furnishings and equipment.
· When a child shows signs of illness, they will be separated from other children until the nature if the illness is determined.

LPA reviewed Forms/Records to Keep in Your Family Child Care Home. Children’s Forms/Records, Facility Forms/Records and Information to be posted, disaster drills, posting requirements, children records requirements, mandated child abuse and injury/death reporting, and criminal record transfer requirements were discussed.

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

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Steven Tung
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KOSTANDYAN FAMILY CHILD CARE
FACILITY NUMBER: 198012716
VISIT DATE: 06/16/2022
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At this time, the licensee’s home does not meet the description of a safe and healthy environment for children as described in Chapter 1, Division 12, Title 22 of the California Code of Regulations. All deficiencies are listed on the 809-D pages and require proof of corrections to be cleared.

Exit interview conducted and report was reviewed with the licensee Karine Kostandyan.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/­­ction-process.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Steven Tung
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC809 (FAS) - (06/04)
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