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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020048
Report Date: 01/17/2023
Date Signed: 01/17/2023 02:51:27 PM

Document Has Been Signed on 01/17/2023 02:51 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:PETROSYAN FAMILY CHILD CAREFACILITY NUMBER:
198020048
ADMINISTRATOR:MARINE PETROSYANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 404-4197
CITY:GLENDALESTATE: CAZIP CODE:
91203
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 9DATE:
01/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Marine Petrosyan, LicenseeTIME COMPLETED:
03:15 PM
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REQUIRED- 1 YEAR INSPECTION CONDUCTED IN ARMENIAN
Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced required 1- year inspection to the above facility on 01/17/2023. LPA arrived at the facility at 12:30 PM and met with Marine Petrosyan Licensee who guided analyst on a tour of the facility. A COVID 19 risk assessment was conducted prior to entering the facility. Also present during this inspection, were Inesa Galstyan, Licensee’s Assistant/Daughter and Verzhine Mirbyan, Volunteer. Per licensee, Marine Petrosyan facility hours are Monday to Saturday from 8:00 a.m. to 5:30 p.m. LPA provided a copy of Entrance Checklist—Family Child Care Home (LIC126) to licensee. Upon LPA's arrival 7 children, four being infants were present in the home. During this inspection two after-school children arrived to the facility.

This is a two story home located on the first floor. There are two additional, detached units in the rear with separated addresses, unit A and B. The units in the rear are rented out and tenants have fingerprint clearances on file.

This home consists of 2 bedrooms, 2 full restrooms, living room (FIREPLACE: inaccessible), and kitchen on the ground floor, the second floor has a storage room and family room (licensee's bedroom), front yard, backyard (fenced), and the basement located outside (locked). Per licensee, parents enter the facility through the main entrance door.

Per licensee the children use the living room, one bedroom, one bathroom in the hallway of bedrooms, kitchen and backyard (fenced). Per licensee, children only walk through the kitchen to go to the backyard. Per licensee areas off limits to children and parents include: One bedroom in the first floor, Second floor which consists of storage room and family room, front yard, and basement. LPA observed stairs which leads to the second floor was inaccessible by a door for children under the age of 5. During this inspection individuals who reside in the home were discussed and notes on Confidential Name List (LIC811) and attached to this report.
REPORT CONTINUES ON NEXT PAGE 1 of 4
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PETROSYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020048
VISIT DATE: 01/17/2023
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All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. At 1:00 p.m., Licensee took this LPA on a tour of the home. LPA was toured through the interior starting with the living room (daycare classrooms), LPA observed a sofa, a TV, five high chairs, one pack n' play, children tables and chairs in the living room. LPA observed all electrical outlets were covered in living room. LPA observed 7 children were playing in the living room, four being infants. Next LPA toured the one bedroom and observed children napping cots and one pack n'play in the bedroom. Next LPA toured the kitchen and observed child proof safety latches on the cabinets where licensee stores sharp items and cleaning compounds. LPA observed a safety gate was installed to the kitchen. Next LPA toured the bathroom in the hallway and did not observe any hazards. LPA observed off-limit bedroom door and door which leads to the second floor were closed during this inspection and had child proof safety latches on it.
LPA observed the required 2A 10BC fire extinguisher was anchored to the wall by the entrance door. It was serviced on 10/04/2022 as read by LPA from the service tag. Licensee tested the carbon monoxide detector in the living room and smoke detector in the hallway of bedrooms. Both sounded off the alarms and heard by LPA to be functional. Detergents, cleaning compounds, medications, and other items which could pose a danger to children were observed to be inaccessible to children. The licensee states at 1:15 p.m. that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock.

Next LPA toured the backyard fenced. Currently, children are using the back yard for outdoor play time. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that can pose a danger to children on the outdoor yard. LPA observed off-limit areas in the backyard are fenced and inaccessible to the children. The licensee states that supervision is always provided.

Per Licensee, Marine Petrosyan at 1:30 p.m there are no pets, weapons, firearms, pools, spas, hot tubs, fish ponds, or similar bodies of water on the premises.
The licensee was observed to be operating within the licensed capacity and is not exceeding the required limitations during this inspection. All adults present have obtained a criminal record clearance on Licensing Information System (LIS). Per licensee, Marine Petrosyan at 12:40 p.m. currently she has one assistant. 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.
REPORT CONTINUES ON NEXT PAGE 2 of 4
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
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: PETROSYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020048
VISIT DATE: 01/17/2023
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The licensee and other personnel have completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 10/2023. Licensee, Marine Petrosyan completed required mandated reporter training on 10/01/2021. There are first aid supplies available on the premises in the kitchen. LPA advised licensee that if a child shows signs of illness he/she/they shall be separated from other children.
At 1:40 p.m., facility roster was reviewed and completed. Per licensee currently there are 9 children enrolled. LPA reviewed 6 children's records, including emergency information from 9 enrolled children, and 3 children were missing immunization on file. The licensee and her assistant have proof of immunization against influenza, pertussis, and measles. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. Last drill documented was conducted on 12/15/2022.
Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted at the wall by the entrance. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that fall into these categories are not permitted in a family child care facility.
Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home. There is telephone service via a landline that is used at the facility during operation hours.
Per licensee she carries liability insurance in accordance with standard established by Family Child Care statue. Signed statements (LIC282) on 5 reviewed files.
INFANT CARE: Licensee states that she is providing care for infants. Per licensee, at 1:10 p.m. currently she has four infants enrolled in her day care, two are over 1 year old and two infants will turn one year old in two days. Licensee states that infants sleep in the living room and daycare bedroom where they are constantly supervised. Appropriate sleeping arrangements and cribs were observed. (one crib for each infant in care was observed). Cribs or play yard did not hinder the entrance or exit from the sleeping space, mattresses shall be firm and covered with a fitted sheet that overlaps the underside so it cannot be dislodged. Cribs and play yards were observed to be free of loose articles and objects. No objects were observed to be hanging above or attached to the side of the crib. LPA did not observe any infants swaddled while in care. LPA advised the Licensee that infants shall be placed on their backs for sleeping and shall be supervised. Infants shall be checked on every 15 minutes and the time of each 15-minute check shall be documented with child’s name and date. The LIC 9227 Individual Infant Sleeping Plan was not completed for two infants who were under 12 months of age. A copy of the LIC 9227 was provided to Licensee. LPA provided the licensee with a copy of A Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. LPA also consulted and explained Child Abuse Reporting, Never Shake a Baby, and Safe Sleeping practices.
REPORT CONTINUES ON NEXT PAGE 3 of 4
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
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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: PETROSYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020048
VISIT DATE: 01/17/2023
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SAFE SLEEP: LPA discussed the safe sleep regulations with licensee, and discussed the Child Care Licensing Safe Sleep webpage at http://www.cdss.ca.gov/inforescources/child-care-licensing/public-information-and-resoucrces/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 http://www/cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Boppy recall: https://www.cpsc.gov/Recalls/2021/The-Boppy-Company-Recalls-Over-3-Million-Original-Newborn-Loungers-Boppy-Preferred-Newborn-Loungers-and-Pottery-Barn-Kids-Boppy-Newborn-Loungers-After-8-Infant-Deaths-Suffocation-Risk
Medication: Incidental Medical Services (IMS) policy was discussed. The licensee states that she will provide IMS. Per licensee, there are no children enrolled that require IMS at this time. 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.

LPA advised the licensee to access forms, regulations and quarterly updates online at: www.ccld.ca.gov.
The following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.
The Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
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 experienced. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding inspection tools and methods, please visit the Program website at www.cdss.gov/inforesouces/community-care-liceinsing/inspection-process
Exit interview conducted and report was reviewed with the Licensee, Marine Petrosyan at 3: 15 p.m..
REPORT END 4 of 4
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/17/2023 02:51 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 01/17/2023 at 02:18 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: PETROSYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 6 children files review, the licensee did not comply with the section cited above in 3 out of 6 children reviewed files, 3 children files did not have immunization records on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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Per licensee, she will obtain a copy of immunization record for child#1, child#2 and child#3 by plan of correction due date.
Plan of correction will be completed by an inspection.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on children file review the licensee did not comply with the section cited above in 2 out of 2 enrolled infants that are under 12 months old did not have Individual Infant Sleeping Plan LIC 9227 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
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Per licensee, child #1 and child #2 will turn one year old in two day. Per licensee, she will obtained completed LIC 9227 for child #1 and child#2 by plan of correction due date.
Plan of correction will be completed by an inspection.
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:Christina Gabelman
LICENSING EVALUATOR NAME:Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023


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