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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020474
Report Date: 03/22/2023
Date Signed: 03/22/2023 04:12:03 PM

Document Has Been Signed on 03/22/2023 04:12 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:KHACHATRYAN & SIMONYAN FAMILY CHILD CAREFACILITY NUMBER:
198020474
ADMINISTRATOR:V.KHACHATRYAN L.SIMONYANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 208-1201
CITY:LOS ANGELESSTATE: CAZIP CODE:
90038
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 13DATE:
03/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Laura Simonyan & Vaghinak Khachatryan, Licensee'sTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mireya García conducted an unannounced annual required inspection. Due to COVID- 19 precautionary measures were taken, licensing staff present during inspection wore appropriate personal protective equipment. LPA met with licensee, Laura Simonyan guided analyst on a tour of the facility. There were thirteen (13) children present during LPA’s arrival with four (4) being infants. Also present was Licensee Vaghinak Khachatryan and Assistant Olga Ulko. There Licensee states that there are currently thirteen (13) children enrolled.

Family members residing in the home are 2 adults (criminal record clearances on file).
This is a two-story home which consists of 3 bedrooms, 2 bathrooms, kitchen, dining room, living room with a fireplace which is inaccessible, detached garage, guest house (vacant) located in the rear of the home and backyard (fenced). The children use the bathroom in the hallway, living room, dining room, bedroom #2 (use for napping purposes) and back yard. Per licensee's, areas off limits to children and parents include: 2 bedrooms, licensee's bathroom, detached garage and guest house. The LPA toured all areas used by children during this visit.
Report continues on next page 1 of 5.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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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Document Has Been Signed on 03/22/2023 04:12 PM - It Cannot Be Edited


Created By: Mireya Garcia On 03/22/2023 at 03:26 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: KHACHATRYAN & SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review of Child #1 file is missing sleeping logs which documents; the physical check of the infant every 15 minutes for labored breathing, signs of distress which includes but is not limited to flushed skin color, increase in body temperature and restlessness. This poses a potential health and safety risk to children in care.
POC Due Date: 03/31/2023
Plan of Correction
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Licensee will began to record and document the physical check of child #1, #3 & #12 sleep every 15 minutes using sleeping log and will then submit logs to LPA Garcia via email by POC due date 03/31/2023.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review of Licensee Laura Simonyan & Vaghinak Khachatryan expired CPR & First aid card. This poses a potential health and safety risk to children in care.
POC Due Date: 03/31/2023
Plan of Correction
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Per Licensee Laura Simonyan & Vaghinak Khachatryan will renewal the pediatric CPR & First aid course and will submit copies of the card to LPA Garcia via email by POC due date 3/31/23
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:Mireya Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/22/2023 04:12 PM - It Cannot Be Edited


Created By: Mireya Garcia On 03/22/2023 at 03:26 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: KHACHATRYAN & SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review of Child #1, file is missing LIC 9227. This poses a potential health and safety risk to children in care.
POC Due Date: 03/24/2023
Plan of Correction
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Per Licensee she will meet with child #1's parent to complete LIC9227 and will place document on file and will submit to LPA Garcia via email on or by POC due date of 03/24/23.
Type B
Section Cited
CCR
102416.5(d)(1)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (1) Twelve children, no more than four of whom may be infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation of 13 children; 4 infants and 9 preschool age children present during today's inspection. This poses a potential health and safety risk to children in care.
POC Due Date: 03/24/2023
Plan of Correction
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Per Licensee Laura, she will disenroll 1 infant (Child #2) from her day care program by the end of 3/22/23 and will submit to LPA Garcia a copy of termination letter by POC due date 03/24/2023
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:Mireya Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023


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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: KHACHATRYAN & SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020474
VISIT DATE: 03/22/2023
NARRATIVE
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During this tour, the following was noted: At 1:35 p.m., LPA was toured through the interior of the home. 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 chimney in the living room that has a sealed closed with plywood. Licensee states there are no poisons in the home. The licensee does understand that poison must be locked with a key or combination lock. There is a working telephone service maintained in the home.

LPA observed and inspected sleeping equipment for infants. LPA observed four (4) cribs for infants who are unable to climb out of the crib. All equipment meets the US Consumer Product Safety Commission safety standards. LPA observed that the cribs are free from loose articles and objects. There are no objects hanging above or attached to the side of the cribs. LPA observed that cribs do not hinder the entrance or exit to and from the space they are sleeping in. Mattresses were observed to be firm and covered with a fitted sheet that is appropriate to the mattress size. Infants in care have their individual bedding and is washed weekly as required. Soiled bedding is replaced when wet or soiled and is placed in an area inaccessible to infants. Pacifiers were not observed. Licensee was advised that infants shall not be swaddled while in care and all infants up to 12 months should be placed on their back for sleeping.
Report continues on next page 2 of 5.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
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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: KHACHATRYAN & SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020474
VISIT DATE: 03/22/2023
NARRATIVE
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LIC 9227 (Individual Sleeping Plan) for infants up to 12 months was review and a copy in English was provided to Licensee. Title 22 Regulation Section 102425(j) Infant Safe Sleep was discussed with the Licensee, including but not limited to documentation that shall be maintained. PIN 20-24-CCP Recently approved Safe Sleep Regulations in Effect was discuss and a copy was also provided in English to the Licensee during this inspection.

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. The valve on the required 2A 10BC fire extinguisher indicates fully charged with a receipt of purchase dated 03/22/2023. There is a dual smoke and carbon monoxide detector located in the hallway near the restroom which was tested at 3:15 p.m., and is in operable condition. The licensee’s Pediatric First Aid and CPR has expired on 10/21 & 11/2021. The licensee’s Assistant has current Pediatric First Aid and CPR, which will expire 01/2025.

Incidental Medical Services (IMS) policy was discussed. Per Licensee there are currently no children enrolled who required IMS. 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 Report continues on next page 3 of 5.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
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: KHACHATRYAN & SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020474
VISIT DATE: 03/22/2023
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SB792 (Immunization Requirements for Staff and Employees) was discussed with the Licensees'.

The following was discussed:
· Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.
· 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 off illness, they will be separated from other children until the nature if the illness is determined.

Report continues on next page 4 of 4.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
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: KHACHATRYAN & SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020474
VISIT DATE: 03/22/2023
NARRATIVE
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LPA reviewed and issued the LIC 311 - 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

The following deficiencies are being cited in accordance to Title 22 of the California Code of Regulations. Please refer to LIC809D for documentation of deficiencies cited.

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

Exit interview conducted and report was reviewed with facility representative, Laura Simonyan & Vaghinak Khachatryan.

Report ends here page 5 of 5.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC809 (FAS) - (06/04)
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