Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015554
Report Date: 03/04/2016
Date Signed 03/07/2016 12:47:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:GHAZARYAN & AVETISYAN FAMILY CHILD CAREFACILITY NUMBER:
198015554
ADMINISTRATOR:RFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 273-4203
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:14CENSUS: 5DATE:
03/04/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:SENIK AVETISYAN & NELL GHAZARYANTIME COMPLETED:
03:10 PM
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ANNUAL/RANDOM VISIT CONDUCTED IN ARMENIAN
Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced random visit. LPA met with , Licensees, Senik Avetisyan and Nella Ghazaryan, who guided analyst on a tour of the facility. Lyudmila Verdyan, Licensee's Assistant was also present during this visit. There were 5 children present during this visit. Licensees state that there are 12 children enrolled, two of who are licensees' biological children. Children’s roster was available during visit.

All areas identified on the facility sketch that children use, were inspected for safety, comfort, cleanliness, telephone service, ventilation and heating (central). This is a one story home which consists of 3 bedrooms, 31/2 bathrooms, kitchen, dining room, living room (FIREPLACE: there is a fireplace which is inaccessible), garage (activity room), laundry room, storage in the backyard, front yard, and backyard (fenced). There is a converted garage in the backyard on the property which consists of on room (activity room), 1 full bathroom, and storage. The children use the bathroom in the living room and converted garage, living room, converted garage (limited activity only), and fenced backyard . Per licensee, areas off limits to children and parents include: 3 bedrooms, kitchen, dinning room, laundry room, storage in the back yard back and 2 bathrooms.

During this visit LPA observed children were eating and sleeping in the living room inside the home. Per licensees, they fully understand that converted garage should be used for limited activity only. (Declaration LIC 855 was received from licensee). Updated facility sketch was received during this visit. Copy of Fire Permit was received during this visit.

The licensees state that 2 adults and 2 children (8 years of age) live in the home. Licensees states that they currently have one full time assistant. All individuals present in the home have obtained a criminal record clearance or exemption prior to working, residing or volunteering in a licensed home.
REPORT CONTINUES ON THE NEXT PAGE 1 OF 3
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3395
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2016
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GHAZARYAN & AVETISYAN FAMILY CHILD CARE
FACILITY NUMBER: 198015554
VISIT DATE: 03/04/2016
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The licensees provide food for children in care. Licensees are enrolled in food program with EVER GREEN.
The home was observed to be clean and orderly during this visit. There is heating and ventilation for safety and comfort. Where children are less than five years old are in care, stairs are fenced or barricaded. There are no stairs in the home. There are toys available for children.

The licensees understand that in their absence a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license. The licensees were observed to be operating within the license capacity limitations during this visit.

All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. Last drill documented was conducted on 02/26/16. The licensee and other personnel have completed training on preventive health practices including Pediatric First Aid and CPR. The licensees' Pediatric First Aid and CPR expire on 12/01/16. There are first aid supplies available.

Children’s records were reviewed, including but not limited to, Immunization Records and Notification of Parents’ Rights receipt for children present. LPA issued the Confidential Names List (LIC 811) to the licensee during this visit. The Confidential Names List (LIC 811) documents the staff and/or children’s files that were reviewed during this visit.

There was NO ZERO TOLERANCE deficiencies cited during this visit. Zero Tolerance includes:
Absence of Supervision; Accessible Bodies of Water. No bodies of water on the premises; Accessible Firearms, Ammunition or Both. No firearms or weapons in the home; Refused Entry to a Facility or Any Part of a Facility in Violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g)(2); The Presence of an Excluded Individual. No excluded individuals; Children are not left in parked vehicles. The facility does not transport children.

The following items were also discussed with licensee during this visit.
PETS: No pets on the premises.
POSTING REQUIREMENTS: Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted. REPORT CONTINUES ON THE NEXT PAGE 2 OF 3
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3395
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2016
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GHAZARYAN & AVETISYAN FAMILY CHILD CARE
FACILITY NUMBER: 198015554
VISIT DATE: 03/04/2016
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SMOKING IS PROHIBITED IN A LICENSED FAMILY CHILD CARE HOME.
INFANT CARE: Licensees state that they do not care for infants. LPA advised the licensee to sleep infants where the infant can be directly supervised. LPA advised against sleeping infants in a separate room. If the licensee chooses to sleep infants in another room, the licensee is advised to conduct periodic checks to the room and a baby monitor is advised to also be used. LPA provided the following documents about SIDS. 1) Safe Sleeping Poster (www.sidsandkids.org)2) CCLD Fall and Winter/Spring 2015 Quarterly Update, Page 5 only

Incidental Medical Services (IMS): Incidental Medical Services were discussed. The licensee states that they do nott offer Incidental Medical Services (IMS).The licensees state that there are currently no children that require prescription inhalers or Epi-Pens. The licensee was advised to submit a plan of operation in 30 days prior. Please refer to Section 102417 for further information on regulatory requirements.

LPA advised the licensees how to access forms, regulations and quarterly updates on line at: www.ccld.ca.gov
LPA discussed and provided the licensees with a packet with updated forms during this visit. Forms provided are as follows: 1) Forms/Records to Keep in your Family Child Care Home (LIC311D), 2) Updated Parents’ Rights Poster w/Complaint Hotline Information (PUB394), 3) Children’s Roster (LIC 9040), 4) Sample Disaster Drill Log, 5) Never Shake a Baby (PUB271), 6) Capacity Handout (Small & Large).

At this time, the licensee is in compliance with California Title 22 Regulations. Therefore, there are no citations being issued today.


The Notice of Site Visit (LIC 9213)must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Recent regulatory changes were discussed (including SB277—Vaccinations, SB792—Immunizations: Exemption, AB 2386—Carbon Monoxide detectors).
Exit interview was conducted with Nella Ghazaryan and Senik Avetisyan, Licensees, including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.
REPORT END 3 OF 3
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3395
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2016
LIC809 (FAS) - (06/04)
Page: 3 of 3