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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198021085
Report Date: 10/24/2022
Date Signed: 10/24/2022 11:53:43 AM

Document Has Been Signed on 10/24/2022 11:53 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:KHACHATRYAN FAMILY CHILD CAREFACILITY NUMBER:
198021085
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
10/24/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Susanna Khachatryan, ApplicantTIME COMPLETED:
12:10 PM
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PRELICENSING INSPECTION CONDUCTED IN ARMENIAN
Licensing Program Analyst (LPA) Anomeh Eivazian conducted an announced pre-licensing inspection to the above facility on 10/24/2022. LPA arrived at the facility at 8:45 AM and met with Susanna Khachatryan, Applicant who guided analyst on a tour of the facility. During this inspection, Liana Sahakyan applicant's daughter was also present. Pre-licensing Entrance Checklist (LIC9280) was provided to applicant, Susanna Khachatryan. During this inspection individuals who reside in the home were discussed and notes on Confidential Name List (LIC811) and attached to this report. Per applicant operation hours will be Monday to Friday, 7:00 a.m. to 7:00 p.m.. Applicant states she will care for children 1-12 years old.

All areas identified on the facility sketch were inspected. This is a two story house located on the second level. The home consists of 3 bedrooms, 2 restrooms, living room, dining room, kitchen, laundry room adjacent to the bedroom in the first floor, guest house in the back of the home on the third level, garage, front yard, and backyard (fenced). There is a pool on the premises, located on the third level of the backyard. Per applicant, parent will enter the facility by using the front yard stairs by the wall which leads to the main entrance door and living room and side gate which leads to the daycare outdoor playarea.

Pool Area (off-limit) is located on the third level in the backyard. Pool is surrounded on three sides by 6 feet high cement and wooded walls and on one side with 4 feet high mesh fence that gate swings inside the pool, self-closed and have a self-latching device located no more than six inches from the top of the gate. Also, on the second level of backyard, prior to the pool area, there is 6 feet high and higher cement and wooden walls to make the pool area inaccessible to the children. (Pictures were taken).

Areas that are accessible to children are as follows: Bathroom in the first floor bedroom, bedroom in the first floor, living room (main daycare area), and backyard (fenced) adjacent to the dining room and living room.
REPORT CONTINUES ON NEXT PAGE 1 of 6
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021085
VISIT DATE: 10/24/2022
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Areas off limits based on facility sketch submitted to children and parents include: Entire second floor which consists of two bedrooms, one bathroom, laundry room adjacent to the bedroom in the first floor, kitchen, dining room, front yard, garage, guest house, second and third level of the backyard, Pool area which is located in the third level of the backyard.
**Rooms that are off-limits need to be made inaccessible during operating hours**

Per applicant children will use the backyard (fenced) adjacent to the dining room and living room for outdoor activity. Children will be physically and visually supervised at all times. The applicant does understand that licensing staff may have access to off-limit areas during inspection visit if necessary.

At 9:30 am, the applicant began touring LPA’s through the home starting with the entry way which lead directly to the living room (daycare area). The living room was inspected and electrical outlets were observed to be covered. There is a fireplace in the living room which has been blocked off to prevent access to children. LPA observed children toys in the living room. LPA observed a safety gate was installed in the living room to make the kitchen and dining room inaccessible. Next LPA toured the off limit dining room and observed a dining table and chairs in the dining room. Next LPA toured the kitchen and observed a sofa, and a coffee table in the kitchen. LPA observed child proof safety latches on the cabinets where applicant stores sharp items and cleaning compounds. Next LPA toured the one bedroom and one bathroom in the first floor and did not observe any hazards. LPA observed a safety gate was installed in the bedroom to make the laundry room inaccessible. Next LPA toured the laundry room adjacent to the first floor bedroom and did not observe any hazards. Next LPA observed a safety gate was installed to the stairs in the first floor which leads to the second floor to make the second floor inaccessible to the children. Next LPA toured the two bedrooms and one bathroom in the second floor and did not observed any hazards. Per applicant, no poisons are kept in the home. LPA observed the required 2A 10BC fire extinguisher was anchored to the wall in the living room. Per applicant it was purchased on 08/2022, applicant was not able to locate the receipt. Applicant tested the carbon monoxide and smoke detectors in the living room. It 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.


REPORT CONTINUES ON NEXT PAGE 2 of 6
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
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 FAMILY CHILD CARE
FACILITY NUMBER: 198021085
VISIT DATE: 10/24/2022
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Next LPA toured the daycare backyard area fenced. Daycare outdoor area is adjacent to the living room and dining room. There is a door in the living room which leads to the outdoor playarea. Also, there is a gate in the outdoor playarea that parents can use for drop off and pick up. LPA observed a child proof safety gate
was installed to the stairs in the backyard to make the rest of the backyard (off-limit) inaccessible to the children. 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. The applicant states that supervision is always provided. Next LPA toured the second level (off-limit) area of the backyard. LPA observed there is 6 feet high and higher concreted and wooden walls in the second level to the make the third level inaccessible to the children. Next LPA toured the guest house (off-limit) which consists of a room and bathroom in the third level of back yard and did not observe any hazards. Next LPA toured the off-limit pool area in the back which is surrounded in three sides by 6 feet high and higher concrete and wooden walls and surrounded on one side by 4 feet high mesh fencing and the pool gate swing inside the pool, self-closed and have a self-latching device located no more than six inches from the top of the gate.

The applicant states that they will provide food for children in care. Applicant 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. Per applicant, at 11:00 am, there are no pets, weapons, firearms on the premises. There are toys available for children. There is not a telephone service available in the home during this inspection. LPA advised applicant that if a child shows signs of illness he/she/they shall be separated from other children. Per applicant no one smokes in the home. There are first aid kit in the home, in the kitchen.

Applicant has proof of CPR and First Aid training as indicated on the certificate. The applicant does have proof of Health and Safety training (completion date:03/26/2022), Pediatric First Aid and CPR (ex. 03/2024). The applicant has proof of immunization against influenza, pertussis, and measles.
Applicant completed required mandated reporter training on 05/05/2022. Mandated reporter training must be completed every 2 years. www.mandatedreporterca.com

The following was discussed with the applicant:
Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 3 of 6
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
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 FAMILY CHILD CARE
FACILITY NUMBER: 198021085
VISIT DATE: 10/24/2022
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-In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.
-A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.
-Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License shall be terminated.
-The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should check and batteries replaced as needed.
-Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
-Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. (use LIC624B for written report)
-Fire and safety drills must be performed every six months and documented for review by the Department.
-Smoking is prohibited in a family child care home.
-Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
-Dog(s) and or pets are recommended to be isolated from children in care.
-No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.
-All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
- Applicant shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.
- Emergency Disaster Plan, Parent’s Rights Poster and the Facility License are required to be posted.
SAFE SLEEP: LPA discussed the safe sleep regulations with applicant 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 applicant 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.
REPORT CONTINUES ON NEXT PAGE 4 of 6
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
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 FAMILY CHILD CARE
FACILITY NUMBER: 198021085
VISIT DATE: 10/24/2022
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INFANT CARE: Applicant states that she will care for infants. Applicant states that infants will sleep in the living room where they are constantly be supervised. Appropriate sleeping arrangements and cribs will be available once an infant being enrolled. LPA informed one crib for each infant in care will be needed. Cribs or play yard shall 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 shall be free of loose articles and objects. No objects shall be hanging above or attached to the side of the crib. LPA informed Applicant infants can not be swaddled while in care. LPA advised the Applicant 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 shall be completed for each infant up to 12 months of age. A copy of the LIC 9227 was provided to Applicant. LPA provided the Applicant 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.

Medication: Incidental Medical Services (IMS) policy was discussed .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

Per applicant, there are no dual licenses at this address. Applicant’s email address was obtained during this inspection. The applicant was advised that email may be public information.



Per applicant, she does not carry liability insurance or a bond in accordance with standard established by Family Child Care statue. Signed statements (LIC282) will be on children’s files. The law requires Family Child Care provider to carry liability insurance or bond in the amount of $300,000 annually or to maintain the signed statement in the facility file.

REPORT CONTINUES ON NEXT PAGE 5 of 6
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021085
VISIT DATE: 10/24/2022
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

The following corrections need to be corrected prior to obtaining a small family child care license. Corrections are due by 11/24/2022.


1. Applicant will add a plastic door knob and a chain lock to the main entrance door for additional safety.
2. Applicant will have a working telephone services available in the home that can stay during daycare operation hours.
3. Applicant will add a gate in the backyard in a way to make the second and third level of the backyard (off-limit) areas inaccessible to the children for additional safety from the pool area .
4. Applicant to submit a DMV change of location proof or updated CA ID under facility address for herself.
5. Applicant will submit an updated facility sketch for Yard plan.
6. Applicant will make the pool gate to swing away from body of water.

A small family child care license will be granted upon receipt of proof of corrections for the above. Once licensed, the applicant is required to adhere to the terms and limitations stated on the license.
The applicant’s signature on this report acknowledges that they have signed the Application for a Family Child Care Home License (LIC 279) under the penalty of perjury that the statements on the application and any attachments are correct.

Exit interview conducted and report was reviewed with the applicant, Susanna Khachatryan at 12:10 p.m..

REPORT END 6 of 6

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC809 (FAS) - (06/04)
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