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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624204
Report Date: 08/22/2023
Date Signed: 08/22/2023 03:35:16 PM

Document Has Been Signed on 08/22/2023 03:35 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:SIMONYAN, MARIYAFACILITY NUMBER:
343624204
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
08/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Mariya SimonyanTIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPAs) Kyrsten Williams and Mandie Goodwin conducted an unannounced annual inspection and met with the Licensee, Mariya Simonyan. LPAs observed four children in care with the licensee. Facility hours of operation are Monday through Friday 7:00 AM - 5:30 PM and Saturdays 9:00 AM - 5:00 PM. LPAs observed that the annual facility fees are current.

LPAs conducted a health and safety inspection and observed that the facility is clean, safe, sanitary, and in good repair with ventilation. LPAs observed the required documents were posted where visible to parents. LPAs observed that there were no hazardous items—such as cleaning compounds, medications, or sharp objects—accessible to children. The fire extinguisher appeared to be in working condition and accessible. LPAs observed the smoke and carbon monoxide detectors are functioning. The facility has equipment and toys safe for children. The backyard is fenced, and the licensee acknowledged that in areas that are not fenced, 100% supervision is required. LPAs observed a creek on the premises with a fence blocking that portion of the property. Licensee acknowledges 100% supervision is required near bodies of water. The licensee stated there are no guns on the premises. Off limit areas include the main house. The licensee acknowledged that children may never enter these off-limit areas.

LPAs did not observe a current children's roster or fire drill log. LPAs observed licensee completing 15 minutes sleep checks, however, there is no documentation of them being completed. LPAs reviewed children’s files and observed that all the required documentation was present in each child's file. LPAs observed the CPR/First Aid certificate was current and expires in October 2024. LPAs discussed with licensee that Mandated Reporter training must be completed every two years and can be completed at www.mandatedreporterca.com. LPAs reviewed staff and facility files and observed the required documentation.


PAGE 1. REPORT CONTINUES ON LIC809-C
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Kyrsten Williams
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SIMONYAN, MARIYA
FACILITY NUMBER: 343624204
VISIT DATE: 08/22/2023
NARRATIVE
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The 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.

During the exit interview, the licensee confirmed that there are no Registered Sex Offenders living in the facility and LPAs completed the RSO profile in FAS.

LPAs discussed the safe sleep regulations with the 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.

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/.

The 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.


PAGE 2. REPORT CONTINUES ON LIC809-C
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Kyrsten Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SIMONYAN, MARIYA
FACILITY NUMBER: 343624204
VISIT DATE: 08/22/2023
NARRATIVE
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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.

Exit interview conducted and report was reviewed with the licensee, Maryia Simonyan.

Deficiencies are cited on the subsequent page of this report (LIC809-D) under the California Code of Regulations, Title 22. The licensee was provided a copy of their Appeal Rights (LIC9058) and the licensee's signature on this form acknowledges receipt of these rights.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Kyrsten Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/22/2023 03:35 PM - It Cannot Be Edited


Created By: Kyrsten Williams On 08/22/2023 at 03:12 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIMONYAN, MARIYA
FACILITY NUMBER: 343624204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in there is no documentation of fire drills bein completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2023
Plan of Correction
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Licensee will send picture verification of the fire drill 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.
SUPERVISOR'S NAME:Natalie Dunaway
LICENSING EVALUATOR NAME:Kyrsten Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/05/2023 08:10 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/05/2023 08:02 PM


Created By: Kyrsten Williams On 08/22/2023 at 03:12 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIMONYAN, MARIYA
FACILITY NUMBER: 343624204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in there is no facility roster on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2023
Plan of Correction
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Licensee will send picture verification of a current facility roster.
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:Seychelle De Luca
LICENSING EVALUATOR NAME:Kyrsten Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
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