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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004136
Report Date: 07/29/2021
Date Signed: 07/29/2021 11:59:31 AM

Document Has Been Signed on 07/29/2021 11:59 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MELIKSETYAN, FLORAFACILITY NUMBER:
384004136
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Flora MeliksetyanTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Marie Rodriguez arrived at home to conduct an unannounced Annual inspection. LPA met with Licensee Flora Meliksetyan and explained purpose of inspection. Present in home were the Licensee, one helper, and five children (2 preschool age and 1 infant plus Licensee's minor children, 1 preschool and 1 school aged). Licensee is operating within capacity requirements on this day. All adults living or working in the home have a criminal record clearance on file. Hours of operation are Monday to Friday from 8:00am to 5:30pm.

Day Care Areas: Lower level only:Bedroom #1, family room, bathroom #1, car port (playing area), and patio. Off Limit Areas: Lower level:Lower master bedroom, lower master bathroom, garage, and sauna in bathroom #1. Upper level:All off limits. LPA toured home with Licensee. LPA observed home to be clean and in good repair with proper temperature and ventilation. There is a variety of age appropriate toys and equipment in the home which are in good condition. Stairwell leading to upper level of home is gated and closed while children are in care. Sauna which is off limits in bathroom #1 is blocked off from children in care and is used as storage for the Licensee. There are no pools, spas, or bodies of water on the property. Outdoor toys and equipment in the car port and patio are age appropriate and in good repair. Car port is completely enclosed with a gate and fencing. All cleaning supplies, poisons, and other chemicals are stored inaccessible to children. There is a working smoke detector and carbon monoxide detector, a fully charged fire extinguisher, and a working telephone. Phone number listed for Licensee is current. Per Licensee, there are firearms in the home which are locked in a secure location in an off limit area out of reach of children.

LPA reviewed three children's records. All children have a record of emergency identification information on file. Licensee and helper record reviewed were complete. Licensee's Pediatric First Aid/CPR certificate expires May 2022. Last emergency drill was conducted in March 2021. Emergency drills are conducted at least once every six months and are properly logged.

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SUPERVISORS NAME: Alma Malig
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2021
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MELIKSETYAN, FLORA
FACILITY NUMBER: 384004136
VISIT DATE: 07/29/2021
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(Continued from LIC 809)

Incidental Medical Services (IMS) was discussed. Licensee has no children who need services 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 Americans with Disabilities Act (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: www.ada.gov/childqanda.htm.

During inspection:
· Licensee was given information regarding PIN 20-24-CCP Safe Sleep Regulation, PIN 20-01-CCP Required Lead Testing for Drinking Water, and Lead Poisoning Facts Flyer.
· Licensee was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622.
· Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years by all staff hired. Training can be taken online at www.mandatedreporterca.com. If training is not available in native language, a statement can be written stating exemption until the translation is available.
· Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
· Licensee was advised for any additional questions to contact CCLD office, Monday to Friday, 8:00am - 5:00pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov.

No deficiencies cited today.

This report was reviewed and discussed with Licensee Flora Meliksetyan. A copy of report was provided

Notice of site visit was observed being posted and shall remain posted for 30 days.
SUPERVISORS NAME: Alma Malig
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC809 (FAS) - (06/04)
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