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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198021539
Report Date: 09/12/2025
Date Signed: 09/12/2025 03:27:21 PM

Document Has Been Signed on 09/12/2025 03:27 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:
198021539
ADMINISTRATOR/
DIRECTOR:		KHACHATRYAN, SUSANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 966-4442
CITY:GLENDALESTATE: CAZIP CODE:
91202
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
09/12/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Susanna Khachatryan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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ANNUAL/RANDOM INSPECTION CONDUCTED IN ARMENIAN

Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced Annual/ Random inspection to the above facility on 09/12/25. LPA arrived at the facility at 12:15 PM and met with licensee, Susanna Khachatryan who guided analyst on a tour of the facility. During this inspection Arusyak Movsisyan, assistant was also present in the home. During this inspection at 1:15 p.m., licensee's assistants, Nona Simonyan and Sona Msryan arrived to the facility. LPA provided a copy of Entrance Checklist—Family Child Care Home (LIC126) to licensee. Per licensee, facility operation hours are Monday to Saturday, 6:00 a.m. to 11:30 p.m.. Licensee states she cares for children 1-13 years old.

This is a one-story home located on the first level. The home consists of 2 bedrooms, 2 restrooms, living room, dining room, kitchen, detached converted garage, front yard, backyard (fenced). Per licensee, parents enter the home through the main entrance which leads to the living room and side gate which leads to the backyard.

Per licensee the children use the bathroom in the kitchen, living room, dining room, kitchen, backyard (fenced), and detached converted garage for limited activity only. Per licensee areas off limits to children and parents include: Two bedrooms, one bathroom in the hallway of bedrooms, and front yard. Licensee, build outdoor play area in the back of backyard (off-limit) and did not inform the licensing. During this inspection, LPA approved licensee to use the entire backyard for outdoor play area. LPA did not observe any stairs in the home during this inspection. During this inspection individuals who reside in the home were discussed and notes on Confidential Name List (LIC811) and attached to this report.


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: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2025
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 8
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)
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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: 198021539
VISIT DATE: 09/12/2025
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All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. At 12:05 p.m., the licensee began touring LPA’s through the home starting with the entry way which led directly to the living room. 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. LPA observed a dining table, chairs, and sofas in the living room. Next LPA toured the dining room and observed children tables, chairs and toys in the dining room. LPA observed children napping cots were placed in the living room and dining room and children took nap in the living room and dining room during this inspection. Next LPA toured the kitchen and observed child proof safety latches on the cabinets where licensee stores sharp items and cleaning compounds. Next LPA toured the bathroom in the kitchen and did not observe any hazards. LPA observed a child safety latch on the cabinet in the bathroom where licensee stores cleaning compounds and personal hygiene. Next LPA toured the two off-limit bedrooms and one off-limit bathrooms in the hallway and did not observe any hazards. LPA observed licensee's family members personal belonging in the home. LPA observed the required 2A 10BC fire extinguisher was anchored to the wall in the kitchen. It was serviced 07/28/25 read by LPA from the service tag. Licensee tested the carbon monoxide and smoke detectors in the 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 licensee, currently children use the entire back yard for outdoor play time. The outdoor play area was observed to be fenced. 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 in the outdoor yard. Outdoor playarea consists of two areas, fenced. LPA observed there is a gate in the backyard which leads to the Olmsted Drive. LPA ask licensee to add a self-closing latch out of reach of children on the side gate for additional safety. Next LPA toured the detached converted garage for limited activity only and observed children toys, tables and chairs in the detached garage. There is a door in the detached converted garage which leads to the off-limit backyard area. Per licensee, children use the detached converted garage for limited activity only, daily from 10:00 AM to 12:00 PM and 3:00 PM to 5:00 PM. Per licensee , children will eat inside the home or outside in the backyard and children will sleep in the main home. LPA informed licensee that detached converted garage can only and only be used for limited activity only and children can not eat and sleep in the detached converted garage.

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 1:10 p.m there are no pets, weapons, firearms, pools, spas, hot tubs, fish ponds, or similar bodies of water on the premises.


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: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
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: 198021539
VISIT DATE: 09/12/2025
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The licensee was observed to be operating within the licensed capacity and is not exceeding the required limitations during this inspection. During this inspection 11 children were present in the home, (2-5 years old) with licensee and her assistant. All adults present have obtained a criminal record clearance on Licensing Information System (LIS). Per licensee, at 1:15 p.m., currently she has four assistants. 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.

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 09/2025. Licensee, Susanna Khachatryan completed required mandated reporter training on 09/29/24. There are first aid supplies available on the premises. LPA advised licensee that if a child shows signs of illness he/she/they shall be separated from other children.

At 1:30 p.m., the facility roster was reviewed and completed. Per licensee currently there are 14 children enrolled. LPA reviewed 6 children's records, including emergency information from 12 enrolled children, and all 6 reviewed files were completed.

The licensee has proof of immunization against influenza, pertussis, and measles. Licensee’s three out of four assistants did not have proof of immunization against measles and pertussis and TB test clearance on file.

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 08/06/25 as read by LPA from disaster drill log. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted at the wall in the dining room.

Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home. There is a 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 6 reviewed files.


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: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC809 (FAS) - (06/04)
Page: 4 of 8
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: 198021539
VISIT DATE: 09/12/2025
NARRATIVE
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INFANT CARE: Licensee states that she is providing care to infants (12-24 months old). Per licensee, currently she does not have infants enrolled in her daycare. Licensee states that infants sleep in the dining room and living room. 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. 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 Licensee.

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.

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.

LPA advised the licensee to access forms, regulations and quarterly updates online at: www.ccld.ca.gov.

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.

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.


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: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC809 (FAS) - (06/04)
Page: 5 of 8
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: 198021539
VISIT DATE: 09/12/2025
NARRATIVE
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A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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

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: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 09/12/2025 03:27 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 09/12/2025 at 01:14 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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021539

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations the licensee did not comply with the section cited above and per licensee she started using the back of backyard as outdoor play area since July but did not report it to licensing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
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Per licensee, she will ensure to follow reporting requirements as it is required effective immediately.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff files review, the licensee did not comply with the section cited above and licensee 3 out of 4 assistants did not have proof of immunization against measles and pertussis on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
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Per licensee, she will submit her 3 assistants proof of immunization against measles and pertussis by 09/30/25.
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: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2025 03:27 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 09/12/2025 at 01:24 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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021539

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on staff file reviews, the licensee did not comply with the section cited above and 2 out of 4 staff did not have TB test clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
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Per licensee, all her staff will have TB test clearance on file by 09/30/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Anomeh Eivazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
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