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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624204
Report Date: 07/15/2022
Date Signed: 07/15/2022 11:31:53 AM

Document Has Been Signed on 07/15/2022 11:31 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:SIMONYAN, MARIYAFACILITY NUMBER:
343624204
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
07/15/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mariya SimonyanTIME COMPLETED:
11:45 AM
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At 9:30 a.m. on Friday, July 15th, 2022, Licensing Program Analyst (LPA) Karyn Guerra met with Applicant, Mariya Simonyan, for the purpose of a prelicensing inspection. The two story home consists of 8 bedrooms and 7 bathrooms, Kitchen, Office, TV room, Formal and Informal Dining Rooms, and Garage. Child care will be conducted in the guest house space. The entire main house will be off limits. Applicant understands that child care children must not enter these off limits areas. Hours of operation are 8:00 a.m - 6:00 p.m., Monday thru Friday and Saturday from 9:00 a.m - 5:00 p.m.

All individuals subject to criminal background review have obtained criminal record clearance. Applicant's father owns the home. Applicant has obtained landlord consent. Proof of control of property has been provided via a mortgage statement. Applicant understands that children living in the home under the age of 10 years count toward the child care ratio count when present at the facility during child care hours.

Applicant has completed the required Preventative Health and Safety course which includes 1 hour of nutrition and lead prevention training. CPR and First aid certification was taken online and expires 1/2023. Applicant understands that CPR certification must be EMSA certified. LPA provided blank forms required for children's records including immunization card. LPA also provided the Parent's Rights form/poster, reviewed vaccination requirements for staff and children, and reviewed COVID-19 guidelines.

Applicant understands 100% supervision shall be maintained in or around bodies of water, and in unfenced areas. There is a creek that runs through the backyard of the property. There is fencing to prevent access to the creek, however, fencing does not meet title 22 regulations.

Applicant stated that there are no weapons nor poisons in the home. Cleaning compounds, knives and medications are inaccessible to children. LPA observed a functioning smoke

report continued on 809-C.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2022
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: SIMONYAN, MARIYA
FACILITY NUMBER: 343624204
VISIT DATE: 07/15/2022
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detector and a carbon monoxide detector in the home. Applicant understands that a current roster must be maintained and that a fire drill must be conducted and documented once every six months.

LPA reviewed updated safe sleep regulations with applicant. LPA did not observe a crib or play yard at the facility. Applicant understands that there shall be one crib or play yard for each infant in care who is unable to climb out of a crib or play yard and an infant sleep plan form LIC9227 shall be kept on file for all infants under 12 months. Applicant understands that infant cribs or play yards shall be free of all loose articles and objects. Applicant understands that they shall physically check on a sleeping infant every 15 minutes and document.



Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. LPA explained to applicant that if they relocate and wants to continue to provide care, they must submit a change of location application and have the new home inspected.

Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624B shall be submitted within seven days to remain in compliance.

Applicant understands that if any changes are made to the off limits of the home; licensing must be notified and a safety inspection conducted prior to any child care children being able to have access to the area.

This facility evaluation report was reviewed and discussed with the applicant. Records, postings and reporting requirements were discussed. LIC311D was provided and discussed. Applicant was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

The following corrections are required prior to licensure:

1. Applicant will correct fencing and gate according to title 22 regulations for bodies of water.

2. Applicant will enroll in EMSA certified CPR course.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC809 (FAS) - (06/04)
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