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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020591
Report Date: 10/21/2021
Date Signed: 10/21/2021 02:21:27 PM

Document Has Been Signed on 10/21/2021 02:21 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:MELKUMYAN FAMILY CHILD CAREFACILITY NUMBER:
198020591
ADMINISTRATOR:SVETIK MELKUMYANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 395-7471
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 8DATE:
10/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Svetik Melkumyan, LicenseeTIME COMPLETED:
02:30 PM
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***CASE MANAGEMENT INSPECTION CONDUCTED IN ARMENIAN***

Licensing Program Analyst (LPA), Anomeh Eivazian, conducted an unannounced case- management inspection to the above facility on 10/21/2021 at 11:45 a.m.. LPA met with Svetik Melkumyan, licensee who guided LPA on a tour of the facility. Also Ashkhen Bakhshyay, licensee's daughter and Arpine Hovsepyan, licensee's assistant were present in the home during this inspection.
During this inspection there were total of 8 children present in the facility, 5 being infants.The licensee was observed not to be operating within the licensed capacity and exceeding the required limitations with one infant.

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



Upon receipt of this report, the Licensee shall post the Notice of Site visit and any licensing report documenting a type “A” deficiency. The report and the Notice of Site visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit. A copy of the Parent Notification Requirements was also provided to the licensee.

Exit interview was conducted with Svetik Melkumyan, licensee at 2:30 p.m.. Appeal Rights procedures explained.

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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 10/21/2021 02:21 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 10/21/2021 at 01:10 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: MELKUMYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2021
Section Cited
CCR
102416.5(d)(2)

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102416.5 (d) (2 ): Staffing Ratio and Capacity : Twelve children, no more than four of whom may be infants; or

This requirements was not met as evidenced by ...

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Per licensee, Svetik Melkumyan she will talk to the parents either to take out one infant or make two infants part time in order to meet the Title 22 Regulation requirements and an updated roster along with a written declaration will be submitted to LPA as proof of correction by plan of correction due date on 10/22/2021.
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Based on LPA Eivazian observation on 10/21/21, during 11:45 a.m. and 2:30 p.m. there were total of 8 children present in the facility, 5 being infants. Licensee was observed not operating within her license limitation and she was over ratio by one infant. This is an immediate health and safety 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: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021


LIC809 (FAS) - (06/04)
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