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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004136
Report Date: 02/13/2024
Date Signed: 02/13/2024 01:41:17 PM

Document Has Been Signed on 02/13/2024 01:41 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MELIKSETYAN, FLORAFACILITY NUMBER:
384004136
ADMINISTRATOR:MELIKSETYAN, FLORAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 606-0525
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94127
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 9DATE:
02/13/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Licensee, Flora MeliksetyanTIME COMPLETED:
02:00 PM
NARRATIVE
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On 2/13/2024, at approximately 11:30AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit at the facility. LPA was granted entry to the facility by Licensee, Flora Meliksetyan. LPA explained the purpose of the visit. Present during the visit was the Licensee, two helpers (H1 and H2), five preschool age children, and four infants. The facility is in compliance with capacity requirements on this day.

Daycare Areas: Lower Level: Office, Family Room, Den, Bathroom, and Backyard.

Off-limits Areas: Entire upper level. Lower Level: Lower master bedroom, master bathroom, and sauna located in Bathroom.

LPA inspected the home for any health and safety hazards. LPA observed the home to be in clean and orderly condition. The home is equipped with two fully charged 2A10BC fire extinguishers. There are three smoke detectors, present in the Office, Family Room, and Den. The carbon monoxide detector is present in the Family Room and was demonstrated to be operational by Licensee. LPA observed age-appropriate toys and learning materials to be present in the home. Cots and cribs are available for use by children in care. LPA observed the cribs to be compliant with safe sleep regulations. Sheets are provided from home by children’s parents.

LPA reviewed three personnel files and nine children’s files. Licensee’s First Aid/CPR training expires 5/2024, and their Mandated Reporter Training expires 3/2024. LPA observed all children’s files to include Emergency Identification and Information (LIC700) and complete immunization records.

Based on record review and interview, LPA found that H2 did not have fingerprint clearance. LPA discussed fingerprinting requirements with Licensee. LPA informed Licensee that a Type-A deficiency will be cited today, and that a civil penalty of $100 will be assessed during the visit. Licensee understood. Licensee stated that H2 would leave the facility and get fingerprinted on this day.
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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MELIKSETYAN, FLORA
FACILITY NUMBER: 384004136
VISIT DATE: 02/13/2024
NARRATIVE
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All required postings (License, Emergency Disaster Plan, Earthquake Preparedness Checklist, and Notification of Parents' Rights) are accessible and available for review upon entry to the facility.

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.

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.

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-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/.

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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MELIKSETYAN, FLORA
FACILITY NUMBER: 384004136
VISIT DATE: 02/13/2024
NARRATIVE
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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.

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

LPA Tse informed licensee Flora Meliksetyan that this report dated 2/13/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Tse informed the licensee to provide a copy of this licensing report dated 2/13/2024 that documents any Type A citation 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 signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

See LIC809-D for Type-A deficiency cited today.
A notice of site visit was given and must remain posted for 30 days. Appeal rights were provided and explained to Licensee.

Exit interview conducted and report was reviewed with the licensee, Flora Meliksetyan.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/13/2024 01:41 PM - It Cannot Be Edited


Created By: Jonathan Tse On 02/13/2024 at 01:20 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MELIKSETYAN, FLORA
FACILITY NUMBER: 384004136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by having a helper without fingerprint clearance present in the home which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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Licensee shall have H2 leave the home to get fingerprinted during today's visit on 2/13/2024. Licensee shall then submit proof of fingerprinting by emailing LPA the completed LIC9163 form.
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:Ali Zebila
LICENSING EVALUATOR NAME:Jonathan Tse
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
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