198020748-5-7-2024-33-CC-SSAN-D52NSE-20240507104300

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198020748
Report Date: 05/07/2024
Date Signed: 05/07/2024 10:43:12 AM

Document Has Been Signed on 05/07/2024 10:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	KHODAGULYAN FAMILY CHILD CARE		FACILITY NUMBER:	198020748
ADMINISTRATOR/ DIRECTOR:	MONIKA KHODAGULYAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 580-8989
CITY:	MONTROSE	STATE: CA	ZIP CODE:	91020
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 4	DATE:	05/07/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	Monika Khodagulyan		TIME VISIT/ INSPECTION COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/07/24 at 8:15 am Licensing Program Analyst (LPA) Shushanik Safaryan conducted an unannounced required 3-year inspection to the above facility. LPA met with Licensee,Monika Khodagulyan, to whom the reason for the visit was explained. Per Licensee, there are 4 children currently enrolled. There were 3 children and licensees son were present upon arrival. The licensee was observed to be operating within the license capacity limitations. The licensee states that 1 adult and 1 minor child currently live in the home. All adults living in the home have obtained a criminal record clearance. This is a one story home which consists of 2 bedrooms, 2 bathrooms, living room, kitchen, office detached garage, laundry room and backyard which is fenced. Care is provided in the living room, two bedrooms, 1 bathroom , backyard and detached garage used as activity room .Per licensee parents enter the home through the Pickens St gate which leads them directly to the backyard . Per licensee, areas off limits to children and parents include Office area , bathroom , kitchen , laundry room. During this visit, all areas identified that are accessible for children to use were inspected for the safety, comfort, and cleanliness. At 08:15 am Licensee guided LPA to the tour of the home. LPA was toured starting from the back gate where parents enter , which leads to the outdoor play area , next LPA toured detached garage which is used for activities only. Per Facility representative she understands that children cannot sleep or eat in the activity room . Next LPA observed laundry room which was locked . From the backyard children enter through the kitchen under licensees’ supervision to the living room, where LPA observed sofa, small tables , chairs, and TV. LPA observed all the sharp items and cleaning compounds inaccessible to the children in care . Next LPA toured bedrooms in the hallway where children nap and observed mats ,play yards . Page 1 of 4

SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: KHODAGULYAN FAMILY CHILD CARE	FACILITY NUMBER: 198020748
	VISIT DATE: 05/07/2024

NARRATIVE

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Per Facility Representative younger children sleep in the play yards .Next LPA toured bathroom located in the hallway that is used for children and did not observe anything hazardous .
Facility License, Emergency Disaster Plan, Parent’s Rights Poster, and Earthquake Preparedness Checklist were observed to be posted in the activity room . A current children’s roster was available for review.

There is telephone service via a cellphone that stays at the facility during operation hours. Hours of operation are Monday – Friday, 8:30 am – 6:00 pm. There is central air and heating in the home. LPA observed fireplace in the living room that is screened making it inaccessible to children.

Detergents, cleaning compounds, and medications were observed to be inaccessible to children. Per Licensee, there are no poisons in the home. LPA advised that any poisons should be locked under key or combination lock. Licensee states that there are no firearms or weapons stored in the home.

The valve on the required 2A 10BC fire extinguisher indicates fully charged and LPA observed service tag with service date 07/26/2023. Smoke and carbon monoxide detectors were tested and are operable.

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 04/23/24.

The home is observed to be clean and orderly. There are first aid supplies available in the kitchen .There are age-appropriate toys available for children.

Per licensee, she provides food for children in care. Licensee was advised that if food is brought from the children’s homes, all containers must be labeled with child’s name and properly stored or refrigerated.

Currently, children are using the backyard for outdoor play time. The outdoor play area was observed to be fenced and gated. 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 danger to children. No bodies of water were observed on this day.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

LIC809 (FAS) - (06/04)

Page: 6 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: KHODAGULYAN FAMILY CHILD CARE	FACILITY NUMBER: 198020748
	VISIT DATE: 05/07/2024

NARRATIVE

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At 09:30 am Licensees records were reviewed. The licensee has completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 04/2026. LPA observed that the Licensee does have proof of Mandated Reporter AB 1207 compliant Child Care Training Certificate on file with expiration on 4/21/24. www.mandatedreporterca.com

At 09:45 am four children’s records were reviewed. Childrens records were incomplete Licensee was missing Consent for Emergency Medical Treatment , Identification and Emergency information for each child. Licensee states she is currently caring for only one infant over 12 months. LPA reviewed with licensee Safe Sleep regulations regarding 15 minutes checks during the nap time for the children over 24 month. LPA created an LIC 857, Children’s Record Review.
Per licensee, there are no animals on the premises.
Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.
LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, and/or any other item that fall into these categories are not permitted in a family childcare facility.

Incidental Medical Services (IMS) policy was discussed. Per Licensee no IMS was provided at this time . For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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/process.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: KHODAGULYAN FAMILY CHILD CARE	FACILITY NUMBER: 198020748
	VISIT DATE: 05/07/2024

NARRATIVE

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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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.

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

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California

During the exit interview, the LICENSEE Monika Khodagulyan confirmed that there are no Registered Sex Offenders living in the facility.

Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (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) – must remain posted for 30 days during the hours of operation after each
site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of
$100.00
An exit interview was conducted, and a copy of this report was provided and explained to Monika Khodagulyan along with Appeal Rights on 05/07/2024.
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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 05/07/2024 10:43 AM - It Cannot Be Edited

Created By: Shushanik Safaryan On 05/07/2024 at 10:28 AM

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: KHODAGULYAN FAMILY CHILD CARE	FACILITY NUMBER: 198020748
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102421(b)

Child's Records

(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, interviewes and records review the licensee did not comply with the section cited above. LPA reviewed 4 children files that were missing forms , which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/21/2024
	Plan of Correction
1 2 3 4	LIcensee wil email copy of the forms to the LPA by POC date .

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Claudia Guangorena

LICENSING EVALUATOR NAME:

Shushanik Safaryan

LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

LIC809 (FAS) - (06/04)

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