198021151-12-27-2022-33-CC-AEIN-CMHPWX-20221227104129

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198021151
Report Date: 12/27/2022
Date Signed: 12/27/2022 10:41:42 AM

Document Has Been Signed on 12/27/2022 10:41 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:	SIMONYAN FAMILY CHILD CARE		FACILITY NUMBER:	198021151
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	12/27/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Karine Simonyan, Applicant		TIME 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	PRELICENSING INSPECTION CONDUCTED IN ARMENIAN Licensing Program Analyst (LPA) Anomeh Eivazian conducted an announced pre-licensing inspection to the above facility on 12/27/2022. LPA arrived at the facility at 8:30 AM and met with Karine Simonyan, Applicant who guided analyst on a tour of the facility. Pre-licensing Entrance Checklist (LIC9280) was provided to applicant, Karine Simonyan. 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 Saturday , 7:00 a.m. to 11:00 p.m.. Applicant states she will care for children 0-12 years old. Applicant previously was licensed at 532 W. Milford Street, Glendale, CA 91203 with facility number 198020423. This is a duplex house, 423-425 West Lexington Drive, Glendale, CA 91203. Both addresses are owned by applicant, Karine Simonyan. A copy of Deed on file. Per applicant, both addresses are occupied by applicant's family. A written declaration obtained from applicant. All areas identified on the facility sketch were inspected. This is a one story duplex home located on the first level. The home consists of 1 bedroom, 1 restroom, living room (main day care area), kitchen, laundry room, detached garage, front yard, back yard (fenced). There is a door in the backyard which leads to the 425 W. Lexington Drive, Glendale, CA 91203. Per applicant, parents will enter the home through the main entrance which leads to the living room main daycare area). Areas that are accessible to children are as follows: Bathroom in the hallway, living room (main daycare area), bedroom, laundry room, and back yard (fenced). Areas off limits based on facility sketch submitted to children and parents include: Kitchen, detached garage and front part of backyard (fenced). Rooms that are off-limits need to be made inaccessible during operating hours REPORT CONTINUES ON NEXT PAGE 1 of 5

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022

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: SIMONYAN FAMILY CHILD CARE	FACILITY NUMBER: 198021151
	VISIT DATE: 12/27/2022

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At 9:00 am, the applicant began touring LPA’s through the home starting with the entry way which lead directly to the living room (main daycare area). The living room was inspected and electrical outlets were observed to be covered. LPA observed children toys, tables and chairs in the living room (main daycare area). Next to the living room, The kitchen was inspected, and LPA observed safety latches on the cabinets where applicant stores sharp items and cleaning compounds. LPA observed a child safety gate was installed to the kitchen to main it inaccessible tot he children. Next LPA toured the bathroom in the hallway and did not observe any hazards. Next LPA toured the one bedroom and observed three cribs and napping cots in the bedroom. Per applicant, no poisons are kept in the home. LPA observed the required 2A 10BC fire extinguisher was anchored to the wall in the laundry room. It was serviced on 07/19/22 as read by LPA from the service tag. Applicant tested the carbon monoxide and smoke detectors in the hallway of bedroom and kitchen. 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. Per applicant, children will use the back of back yard for outdoor play time which is fenced with 6 feet high gates and separated from off-limit areas in the backyard. Per applicant, children will line up and under supervision will walk to the outdoor play area. 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. There is a door in the backyard which leads to the 425 W. Lexington Drive home. Per applicant, she will keep the 425 W. Lexington Drive home door in the backyard closed all the times.

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 10:00 am, there are no pets, weapons, firearms or bodies of water on the premises. There are toys available for children. There is telephone service via a landline that is used at the facility during operation hours. 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 living room.

REPORT CONTINUES ON NEXT PAGE 2 of 5

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022

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: SIMONYAN FAMILY CHILD CARE	FACILITY NUMBER: 198021151
	VISIT DATE: 12/27/2022

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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:07/27/2019) missing Lead Poising training, Pediatric First Aid and CPR (ex. 07/2023). The applicant has proof of immunization against influenza, pertussis, and measles. Applicant completed required mandated reporter training on 07/26/2021. 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.
-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.

REPORT CONTINUES ON NEXT PAGE 3 of 5

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: SIMONYAN FAMILY CHILD CARE	FACILITY NUMBER: 198021151
	VISIT DATE: 12/27/2022

NARRATIVE

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-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.

INFANT CARE: Applicant states that she will care for infants. Applicant states that infants will sleep in the living room and bedroom 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.

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 5

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: SIMONYAN FAMILY CHILD CARE	FACILITY NUMBER: 198021151
	VISIT DATE: 12/27/2022

NARRATIVE

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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.
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 01/27/2023:
1. Applicant will make the two AC units inaccessible to the children in the backyard.
2. Applicant will submit TB test clearance for Grigor Simonyan and Amalya Kyatunts.
3. Applicant will submit updated Preventative Health and Safety training certificate.
4. Applicant will add an additional door lock on the main entrance door for safety.
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, Karine Simonyan at 11:00 AM.
REPORT END 5 of 5

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022

LIC809 (FAS) - (06/04)

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