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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198021085
Report Date: 11/14/2025
Date Signed: 11/14/2025 02:27:02 PM

Document Has Been Signed on 11/14/2025 02:27 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 FAMILY CHILD CAREFACILITY NUMBER:
198021085
ADMINISTRATOR/
DIRECTOR:		SUSANNA KHACHATRYANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(747) 272-4107
CITY:GLENDALESTATE: CAZIP CODE:
91207
CAPACITY: 14TOTAL ENROLLED CHILDREN: 1CENSUS: 2DATE:
11/14/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Susanna Khachatryan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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ANNUAL/RANDOM INSPECTION CONDUCTED IN ARMENIAN

Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced required-3 year inspection to the above facility on 11/14/25. LPA arrived at the facility at 11:00 AM and met with Susanna Khachatryan, Licensee who guided analyst on a tour of the facility. During this inspection Liana Sahakyan, licensee’s daughter in-law, Seyran Sargsyan, licensee’s son and licensee’s two biological grand children were present in the home. Per licensee, Susanna Khachatryan facility hours are Monday to Saturday from 7:00 a.m. to 12:00 a.m.. Per licensee, she provides care to 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, 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 in the backyard. Per licensee, parent enter the facility by using the front yard stairs by the wall which leads to the main entrance door and living room.

Per licensee, the children use the bathroom in the first floor bedroom, bedroom in the first floor, living room (main daycare area), and backyard (fenced) adjacent to the kitchen and living room.

Per licensee areas off limits 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, front yard, garage, guest house, second and third level of the backyard, and Pool area which is located in the third level of the backyard.


REPORT CONTINUES ON NEXT PAGE 1 of 5
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 9
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: 11/14/2025
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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 away from body's of water, self-closed and have a self-latching device. There is a gate in the pool area which leads to the Alamo Dr.. 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. On the outdoor playarea LPA observed a child safety gate was installed to the stairs which leads to the off-limit areas in the backyard to make the off-limit areas in the backyard inaccessible to the children. Per licensee, she keeps the pool mesh fencing gate locked all the times. LPA observed licensee used the key to unlock the mesh pool gate.

LPA provided documentation that mesh fencing is required to be compliant with American Society for Testing and Materials (ASTM) International Standard F2286. LPA did not observe an alarm in the swimming pool. A life ring with a minimum exterior of 17 inches and labeled as approved by the United Stated Coast Guard and a rescue pole with a body hook and a minimum fixed length of 12 feet were not available visible from the swimming pool and readily available for immediate use. Per licensee she did not perform a daily inspection of the drawing prevention safety feature and safety equipment before opening the facility and did not complete log of the inspections.

LPA advised licensee to add door alarms on the main entrance door and doors in the kitchen and living room which leads to the outdoor playarea for additional safety. A copy of AB-2866 Pool Safety was provided to licensee during this inspection.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. At 11:05 a.m., Licensee took this LPA on a tour of the home. LPA was toured through the interior starting with 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’s toys in the living room. LPA observed a safety gate was installed in the living room to make the kitchen inaccessible. LPA observed a child safety gate was installed to the stairs in the living room which leads to the second floor to make the second floor inaccessible to the children. Next LPA toured the off-limit kitchen and observed a sofa, and a coffee table in the kitchen. LPA observed child proof safety latches on the cabinets where licensee stores sharp items and cleaning compounds. Next LPA toured the one bedroom and one bathroom on 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. LPA observed licensee's family members personal belongings in the home.


REPORT CONTINUES ON NEXT PAGE 2 of 5
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
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: 11/14/2025
NARRATIVE
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Next LPA toured the laundry room adjacent to the first-floor bedroom and did not observe any hazards. Per licensee, no poisons are kept in the home. LPA observed the required 2A 10BC fire extinguisher was anchored to the wall in the living room. It was serviced on 11/15/23 as read by LPA from service tag. Fire extinguisher was not serviced annually as it is required. Licensee 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.

Next LPA toured the backyard fenced. Currently, children are using the daycare level back yard for outdoor play time. Per licensee, children use the living room door to enter the backyard. The outdoor play area was observed to be fenced. LPA observed 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. LPA observed a child safety gate was installed to the stairs in the backyard to make the second and third level of backyard inaccessible to the children. LPA observed the side gate in the backyard which leads to the driveway, has chain lock, out of reach of 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. Per Licensee, at 12:10 p.m there are no weapons, and firearms on the premises. Per licensee, there is a dog on the premises which is inaccessible to the children.

The licensee was observed to be operating within the licensed capacity and is not exceeding the required limitations during this inspection. Per licensee, currently she has one after school child enrolled in her daycare. All adults present have obtained a criminal record clearance on Licensing Information System (LIS). Per licensee, currently she has one assistant. Licensee was reminded that all adults 18 and over living or working in the home, 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 5
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC809 (FAS) - (06/04)
Page: 4 of 9
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: 11/14/2025
NARRATIVE
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The licensee and other personnel have completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 03/2026. Licensee, Susanna Khachatryan completed required mandated reporter training on 11/09/2025. There are first aid supplies available on the premises in the first floor bathroom. LPA advised licensee that if a child shows signs of illness he/she/they shall be separated from other children.

At 12:40 p.m., facility roster was reviewed and completed. Per licensee currently there is one after-school child enrolled. LPA reviewed one child's record, including emergency information and it was completed.

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 10/14/25. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted at the wall by the entrance in the living room. Per licensee, she provides transportation to the children.

LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that fall into these categories are not permitted in a family child care facility. Smoking is prohibited in a licensed Family Child Care Home.

Per Licensee, her husband and son smoke but outside in the off-limit areas. There is telephone service via a cellphone that is used and the cellphone stays at the facility during operation hours. Per licensee she does not carry liability insurance or a bond in accordance with standard established by Family Child Care statue. Signed statements (LIC282) on one reviewed file.

INFANT CARE: Licensee states that currently she does not have any infants enrolled in her daycare. Licensee states that if an infant is enrolled, the infant will sleep in the first floor bedroom where they are constantly supervised. LPA advised the Licensee 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.

Medication: Incidental Medical Services (IMS) policy was discussed. The licensee states that she will provide IMS. Per licensee, there are no children enrolled that require IMS at this time. 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 4 of 5
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC809 (FAS) - (06/04)
Page: 5 of 9
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: 11/14/2025
NARRATIVE
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SAFE SLEEP: LPA discussed the safe sleep regulations with licensee, and discussed the Child Care Licensing Safe Sleep webpage at http://www.cdss.ca.gov/inforescources/child-care-licensing/public-information-and-resoucrces/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 http://www/cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Boppy recall: https://www.cpsc.gov/Recalls/2021/The-Boppy-Company-Recalls-Over-3-Million-Original-Newborn-Loungers-Boppy-Preferred-Newborn-Loungers-and-Pottery-Barn-Kids-Boppy-Newborn-Loungers-After-8-Infant-Deaths-Suffocation-Risk

The following deficiencies listed on the attached LIC 809 (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.



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

During the exit interview, the Licensee, Susanna Khachatryan confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.

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

Exit interview conducted and report was reviewed with the licensee, Susanna Khachatryan.
REPORT END 5 of 5
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 11/14/2025 02:27 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 11/14/2025 at 11:54 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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above and fire extinguisher was serviced on 11/25/23 and it was not serviced annually as it is required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2025
Plan of Correction
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Per licensee, she will service the fire extinguisher by 12/26/25.
Type B
Section Cited
HSC
1596.814(a)(1)(A)(vi)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (1) The swimming pool shall be equipped with, at minimum, the following drowning prevention safety features: (A) An enclosure, including, but not limited to, a fence, wall, or other barrier that isolates the swimming pool from access to the family daycare home and has all of the following characteristics: (vi) For mesh fencing that does not meet the above characteristics, the licensee must provide documentation that establishes the mesh fencing is compliant with the American Society for Testing and Materials (ASTM) International Standard F2286.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above the licensee was not able to provide documentation that mesh fencing is complaint with ASTM F2286 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2025
Plan of Correction
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Per licensee, she will ensure the pool mesh fencing to meet ASTM F2286 and have required documentation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Anomeh Eivazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 11/14/2025 02:27 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 11/14/2025 at 11:54 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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(1)(B)(ii)(I)
Pool Safety
(ii) (I) An alarm that, when placed in a swimming pool, will sound upon detecting an entrance into the water. The alarm shall be turned on and be in working condition during a facility’s operating hours while the swimming pool is not in use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above and licensee did not have required pool alarm in the pool which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2025
Plan of Correction
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Per licensee, she will have the required pool alarm by 12/26/25.
Type B
Section Cited
HSC
1596.814(a)(2)(A)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (A) A life ring with a minimum exterior diameter of 17 inches and labeled as approved by the United States Coast Guard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above and LPA did not observe required life ring in the pool area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2025
Plan of Correction
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Per licensee, she will have the required life ring with a minimum exterior diameter of 17 inches and labeled as approved by the United States Coast Guard by 12/26/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Anomeh Eivazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 11/14/2025 02:27 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 11/14/2025 at 11:54 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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.814(a)(2)(B)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: (B) A rescue pole with a body hook and a minimum fixed length of 12 feet.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on LPA's observation, the licensee did not comply with the section cited above and licensee did not have required rescue pole with a body hook in the pool area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2025
Plan of Correction
1
2
3
4
Per licensee, she will have the required rescue pole with a body hook and a minimum fixed length of 12 feet by 12/26/25.
Type B
Section Cited
HSC
1596.814(a)(3)
Pool Safety
(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (3) A licensee shall perform a daily inspection of the drowning prevention safety features and safety equipment before opening the facility and maintain a log of the inspections to be provided to the department upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and licensee statement the licensee did not comply with the section cited above licensee did not perform daily pool inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2025
Plan of Correction
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Per licensee, she will conduct a daily inspection of the drowning prevention safety features and safety equipment before opening the facility and maintain a log of the inspections to be provided to the department upon request.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Anomeh Eivazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2025


LIC809 (FAS) - (06/04)
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