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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343621305
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:18:23 PM

Document Has Been Signed on 10/30/2023 02:18 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MELIKYAN, NUNEFACILITY NUMBER:
343621305
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nune MelikyanTIME COMPLETED:
01:45 PM
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Licensing Program Analyst Erwina Pascual-Golamco (LPA) conducted an unannounced annual inspection and met with Licensee, Nune Melikyan. All individuals subject to criminal background review have obtained a criminal record clearance. LPA observed 4 children in care with licensee and cleared assistant. Facility hours of operation are Monday through Friday 7:00 AM – 10:00 PM. LPA observed that the annual facility fees are current.
Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Off-limit areas include: MASTER BEDROOM, MASTER BATHROOM, LAUNDRY ROOM, GARAGE, BEDROOM #1 AND SIDE YARDS. License stated Bedroom #2 is also off limits. The backyard is fenced and gated but Licensee stated it is still off limits since last annual visit, 08/30/22. Licensee acknowledged that children may never enter these off-limit areas. LPA conducted a health and safety inspection and observed that the facility has heating and ventilation for safety and comfort, LPA provided technical assistance regarding safe sleep regulations, and observed infant was sleeping on a bed surrounded with pillows and blankets in an off limits area during facility hours of operation. Licensee moved infant to a pack and play in an area accessible to children. LPA observed the fireplace is barricaded, and the facility is a one story home. The facility has equipment and age-appropriate materials for children. LPA observed the required posting documents and provided technical assistance to post where visible to parents. During inspection, LPA observed hazardous items accessible to children. Licensee moved items and placed on top shelf in kitchen pantry and garage. continued on LIC809C...
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MELIKYAN, NUNE
FACILITY NUMBER: 343621305
VISIT DATE: 10/30/2023
NARRATIVE
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The 2A-10-BC fire extinguisher appeared to be in working condition and is accessible. LPA observed the smoke and carbon monoxide detectors are functioning. Licensee stated there are no weapons or firearms on the premises. The backyard is fenced, and licensee acknowledged that in areas that are not fenced, 100% supervision is required. LPA did not observe bodies of water on the premises although LPA observed a dry water fountain in the front yard. Licensee stated that fountain is drained but will fill the basin with river rocks to the water level if rain starts to fill.

LPA observed a current children's roster and fire drill log which was last conducted on 08/03/23. LPA reviewed children’s files and provided technical assistance regarding required documentation. LPA observed the CPR/First Aid certificate was valid until 06/24. Mandated Reporter Training (MRT) certificate was valid until 08/24. Licensee was reminded both CPR/First Aid and MRT Child Care portion must be completed every two years. LPA reviewed facility files and technical assistance provided regarding staff required documentation.

LPA discussed the safe sleep regulations with licensee and the Child Care Licensing Safe Sleep webpage at
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the https://mychildcareplan.org/; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.
continued on LIC809C...


SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
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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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MELIKYAN, NUNE
FACILITY NUMBER: 343621305
VISIT DATE: 10/30/2023
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Based on the inspection, interview, and record review, Type A Title 22 Deficiencies have been issued on the attached LIC 809-D page. The Licensee shall also provide a copy of this licensing report to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report.

A Notice Of Site visit was given to licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. A signed Acknowledgement of Receipt of the Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS on 10/27/23. Licensee has been provided with appeal rights. Exit interview was conducted, report was reviewed with the licensee, Nune Melikyan.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
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Document Has Been Signed on 10/30/2023 02:18 PM - It Cannot Be Edited


Created By: Erwina Pascual-Golamco On 10/30/2023 at 11:24 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MELIKYAN, NUNE
FACILITY NUMBER: 343621305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview, the licensee did not comply with the section cited above as LPA observed cleaning compound under kitchen sink that was not locked and is accessible to children which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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 Licensee moved items and placed on top shelf in kitchen pantry and garage. Deficiency cleared at time of LPA visit.
Type A
Section Cited
CCR
102425(i)
Infant Safe Sleep
If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, licensee did not comply with the section cited above as LPA observed infant asleep on the bed surrounded with pillows and blankets in an off limits area which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee moved infant to a pack and play in an area accessible to children. Deficiency cleared at time of LPA visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Natalie Dunaway
LICENSING EVALUATOR NAME:Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


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Page: 2 of 6
Document Has Been Signed on 10/30/2023 02:18 PM - It Cannot Be Edited


Created By: Erwina Pascual-Golamco On 10/30/2023 at 11:24 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MELIKYAN, NUNE
FACILITY NUMBER: 343621305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 observation, interview, and record review, the licensee did not comply with the section cited above as LPA observed infant asleep on the bed surrounded with pillows and blankets in an off limits area during facility hours which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee moved infant to a pack and play in an area accessible to children. Deficiency cleared at time of LPA visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Natalie Dunaway
LICENSING EVALUATOR NAME:Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2023 02:18 PM - It Cannot Be Edited


Created By: Erwina Pascual-Golamco On 10/30/2023 at 11:24 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MELIKYAN, NUNE
FACILITY NUMBER: 343621305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(d)
Personnel Records
(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as LPA did not observed required documentation for cleared assistant, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Licensee stated she will get required documentation for assistant and will email LPA attestation statement that it is complete and in assistant's file by 4pm on POC due date.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as LPA did not observe LIC9227 in infant's file. Licensee stated infant was enrolled 6 months ago, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Licensee stated she will get required documentation and will email LPA attestation statement that it is complete and in infant's file by 4pm on POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Natalie Dunaway
LICENSING EVALUATOR NAME:Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


LIC809 (FAS) - (06/04)
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