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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020558
Report Date: 05/20/2024
Date Signed: 05/20/2024 02:54:46 PM

Document Has Been Signed on 05/20/2024 02:54 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:KOSTANYAN FAMILY CHILD CAREFACILITY NUMBER:
198020558
ADMINISTRATOR/
DIRECTOR:		EMMA KOSTANYANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 468-9418
CITY:GLENDALESTATE: CAZIP CODE:
91206
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
05/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Emma Kostanyan, ApplicantTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Anomeh Eivazian, conducted an unannounced case- management inspection to the above facility on 05/20/24 at 12:10 PM. LPA met with Emma Kostanyan, licensee who guided LPA on a tour of the facility.

Upon LPA's arrival to the facility at 12:10 PM, licensee was not present in the home. LPA heard children sounds from front porch window. LPA observed children were present in the dining room with one staff. LPA rang the door bell, no one opened the door. LPA contacted licensee who stated she is on her way to the facility. LPA asked licensee to let the LPA inside but staff did not open the door. At 12:30 PM licensee arrived to the facility and let the LPA inside the home. At 12:30 PM, LPA observed eight children were present in the home with two staff


Upon LPA's arrival to the facility from 12:10 PM to 12:30 PM there were total of 8 children present in the facility, all being 2-5 years old, with licensee's two assistants, Siran Grigoryan and Nora Sergoyan.

Licensee's assistant, Siran Grigoryan who was present in the home during this inspection did not have criminal record clearance on file.

During this inspection licensee's son, Lyova Kostanyan was also present in the home in the second floor, who did not have criminal record clearance on file.

During this inspection licensee did not have her current facility roster.

The following are being cited in accordance to Title 22 of the California Code of Regulations. Please refer to 809D for cited deficiencies.

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SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KOSTANYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020558
VISIT DATE: 05/20/2024
NARRATIVE
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LPA Eivazian informed licensee, Emma Kostanyan that this report dated 05/20/24 document(s) (1 Type A citation) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Eivazian informed the licensee, Emma Kostanyan to provide a copy of this licensing report dated 05/20/24 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

The Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days.


Exit interview conducted and report was reviewed with the licensee, Emma Kostanyan.
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SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/20/2024 02:54 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 05/20/2024 at 01:47 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: KOSTANYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2024
Section Cited
CCR
102370(d)(1)

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Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: etc..
This requirement was not met as evidenced by...
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Per licensee, her son and her assistant, Siran Grigoryan will complete required criminal record clearance and a copy of Livescan request form LIC 9163 will be submitted to LPA.
$1000 immediate civil penalty was assessed on this date.
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During this inspection licensee's son, Lyova Kostanyan and licensee's assistant, Siran Grigoryan were present in the home, who did not have criminal record clearance on file.
This poses an immediate health, safety and personal right risk to the children care.
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LPA informed licensee that her assistant can not be present in the home until grant criminal record clearance in Licensing Information System.

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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:Christina Gabelman
LICENSING EVALUATOR NAME:Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/20/2024 02:54 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 05/20/2024 at 01:58 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: KOSTANYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2024
Section Cited
CCR
102714(g)(8)

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Operation of a Family Child Care Home
Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
This requirement was not met as evidenced by...
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Per licensee, she will have her current facility roster by plan of correction due date and a copy will be submitted to LPA.
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During this inspection licensee did not have her current facility roster.

This poses a potential health, safety and personal right risk to the children in care.
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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:Christina Gabelman
LICENSING EVALUATOR NAME:Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024


LIC809 (FAS) - (06/04)
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