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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191213998
Report Date: 04/23/2025
Date Signed: 04/24/2025 09:08:53 AM

Document Has Been Signed on 04/24/2025 09:08 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:GERGOV FAMILY DAY CAREFACILITY NUMBER:
191213998
ADMINISTRATOR/
DIRECTOR:		DELKA D. GERGOVFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 845-5048
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 7DATE:
04/23/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Licensee / Delka GergovTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 4/23/25, at 8:30AM, Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an Unannounced Required – 3 Year inspection to the above facility. Upon arrival, LPA met with Licensee / Delka Gergov and disclosed the purpose of the inspection. Licensee guided the LPA on a tour of the facility. Entrance Checklist – Family Child Care Homes was provided to the Licensee. Adults in the home were discussed and all have criminal record clearance. Also present was Maria Mejia, Licensee’s Assistant. There were 7 day care children present during today’s inspection, of which 3 are infants. Licensee states that there are currently 7 children enrolled. The children's roster was reviewed and is current. Per licensee, the facility’s hours of operation are 7:30 AM to 5:30 PM, Monday through Friday. Facility is closed all major holidays. Emergency Disaster Plan, License, and Parents’ Rights were posted at the time of inspection.

This is a single story home which consists of 3 bedrooms, 2 bathrooms, kitchen, dining room, living room, family room/den and an attached garage. Guest home in back of home is utilized for children’s activities and play time. Areas used by the children include the family room/den, bedrooms 1 and 3, kitchen, bathroom 2, back yard and guest home. Per Licensee, areas off limits to children include living room, dining room, bedroom 2 and bathroom 1. LPA did not observe baby gates separating off-limit areas. Also, no locks or child safety mechanisms were observed on the doors leading to bedroom 2 and bathroom 1. During the visit, Licensee refused to install baby gates separating the off-limit areas and locks or child safety mechanisms on doors to bedroom 2 and bathroom 1. Sharp knives were found in a bag located in the kitchen drawer. The kitchen drawer was not locked, making the knives accessible to children. The washer and dryer are located inside bathroom 2, behind a set of doors. Detergent and bleach are also stored in this area. At the time of observation, the doors were not locked, making the detergent and bleach accessible to children in care. Sleeping area for infants was observed in Room 1.
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NAME OF LICENSING PROGRAM MANAGER: Rita Ramos
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GERGOV FAMILY DAY CARE
FACILITY NUMBER: 191213998
VISIT DATE: 04/23/2025
NARRATIVE
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All areas identified on the facility sketch as accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for the safety of the children. There is a working telephone maintained in the home. LPA observed age appropriate toys, free of loose and sharp parts. LPA observed electrical cover outlets all through the home. The Licensee states that there are no poisons in the home. The Licensee does understand that poison must be locked with a key or combination lock. Per licensee, there are no pets and LPA did not observe any pets at the time of visit. Per Licensee, isolation area for sick children is in the family room/den.

Per licensee, the children will have access to backyard area. LPA observed backyard has grass and adequate perimeter fencing through-out the yard. LPA advised Licensee that outdoor supervision is required at all times. LPA observed age appropriate toys free of loose and sharp parts available for the children in the backyard and all trees, shrubs, and plants are maintained. Each family child care home shall conduct fire drills and disaster drills at least once every six months. The Licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home. Disaster drill log was available during today’s inspection, last disaster drill conducted on 1/13/25. Per Licensee, there are no weapons, firearms in the home and there are no bodies of water around the premises.

Per licensee, the facility does not provide food for children in care. Children bring their own lunch to the facility and Licensee only provides a PM snack. Food preparation areas were toured for safety, cleanliness and proper equipment.

The valve on the required 2A 10BC fire extinguisher indicates fully charged. Smoke and carbon monoxide detectors are in operable condition. The Licensee has current Pediatric First Aid and CPR. Proof of immunization against pertussis, and measles was readily available during today’s inspection. Licensee did not have a current Mandated Reporter Training certificate on file.

— Pediatric First Aid and CPR Card valid until: 2/22/2027

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding

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NAME OF LICENSING PROGRAM MANAGER: Rita Ramos
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GERGOV FAMILY DAY CARE
FACILITY NUMBER: 191213998
VISIT DATE: 04/23/2025
NARRATIVE
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Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Rooms that are off-limits need to be made inaccessible during operating hours. NO smoking, NO infant walkers, NO Johnny jumpers, NO saucer chairs, NO incline sleepers and any other item that falls into that category are permitted in the facility. Effective January 1, 2010, licensees of family child care homes are required to ensure that at least one staff member with current training in pediatric first aid and pediatric CPR is on site at all times when children are present.



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-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.

LPA reviewed and issued the LIC 311D - Forms/Records to Keep in Your Family Child Care Home. Mandatory Forms for the children’s files and staff files, requirements for fire drills, earthquake drills and documentation were discussed. Role and responsibilities of being a Mandated Reporter were reviewed. The Licensee was advised how to access forms and Regulations online at www.ccld.ca.gov. Licensee was made aware that it is his/her responsibility to know the regulations as well as anyone who assists in providing care.



AB 1207: Beginning on January 1, 2018, this law requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training
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NAME OF LICENSING PROGRAM MANAGER: Rita Ramos
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GERGOV FAMILY DAY CARE
FACILITY NUMBER: 191213998
VISIT DATE: 04/23/2025
NARRATIVE
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every two years. Volunteers are encouraged but not required to take the training. Website: http://www.mandatedreporterca.com/

Senate Bill 792: this bill, commencing September 1, 2016, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles. LPA discussed the influenza waiver during the visit.

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.

MyChildCarePlan.org – Centers and Family Child Care Homes Licensee [or facility representative] 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. Megan’s Law - Family Child Care Homes

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

The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D).

Upon receipt of this report, the Licensee shall post the Notice of Site Visit and any Licensing report


documenting a type “A” deficiency. The report and the Notice of Site Visit shall be posted for 30 consecutive
days. Failure to maintain posting as required, will result in an immediate $100 civil penalty. A copy of this
report shall be provided to the parent/guardian of children currently enrolled by the next business day or
immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly
enrolled children for the next 12 months (1 year). The Acknowledgement of Receipt (LIC 9224 form must be
maintained in each child ’s file immediately upon receipt from parent. Licensee was provided with a copy of
the Acknowledgement of Receipt of Licensing Reports (LIC 9224) Form during this visit.

A notice of site visit was given and must remain posted for 30 days. Exit interview was conducted and report was reviewed with the Licensee and Appeals Rights provided.


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NAME OF LICENSING PROGRAM MANAGER: Rita Ramos
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 04/24/2025 09:08 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 04/23/2025 at 02:06 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GERGOV FAMILY DAY CARE
FACILITY NUMBER: 191213998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. Per Licensee, areas off limits to children include living room, dining room, bedroom 2 and bathroom 1. LPA did not observe baby gates separating off-limit areas. Also, no locks or child safety mechanisms were observed on the doors leading to bedroom 2 and bathroom 1. During the visit, Licensee refused to install baby gates separating the off-limit areas and locks or child safety mechanisms on doors to bedroom 2 and bathroom 1. Sharp knives were found in a bag located in the kitchen drawer. The kitchen drawer was not locked, making the knives accessible to children. The washer and dryer are located inside bathroom 2, behind a set of doors. Detergent and bleach are also stored in this area. At the time of observation, the doors were not locked, making the detergent and bleach accessible to children in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2025
Plan of Correction
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The Director will review Title 22 Regulations Section 102417 on Operation Of A Family Child Care Home and ensure compliance within this section. Proof of correction on the items listed above must be submitted to Community Care Licensing (CCL) by the Plan of Correction (POC) due date of 4/24/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Rita Ramos
NAME OF LICENSING PROGRAM MANAGER:
Joe Katrdzhyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 04/24/2025 09:08 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 04/23/2025 at 02:06 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GERGOV FAMILY DAY CARE
FACILITY NUMBER: 191213998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. The Licensee and Staff 1 did not have a current Mandated Reporter Training certificate on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Licensee and Staff 1 will complete the Mandated Reporter Training and submit copies of the Mandated Reporter Training certificates to CCL by the POC due date of 5/23/25.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. Immunization records (pertussis & measles) were missing for Staff 1, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Licensee will submit copies of the immunization records (pertussis & measles) for Staff 1, to CCL by the POC due date of 5/23/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Rita Ramos
NAME OF LICENSING PROGRAM MANAGER:
Joe Katrdzhyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 04/24/2025 09:08 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 04/23/2025 at 02:06 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GERGOV FAMILY DAY CARE
FACILITY NUMBER: 191213998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. An Individual Infant Sleeping Plan (LIC 9227) was missing for Child 1 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
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Licensee will complete the Individual Infant Sleeping Plan (LIC 9227) for Child 1 and submit a copy to CCL by the POC due date of 4/30/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Rita Ramos
NAME OF LICENSING PROGRAM MANAGER:
Joe Katrdzhyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 04/24/2025 09:08 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 04/23/2025 at 02:27 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GERGOV FAMILY DAY CARE
FACILITY NUMBER: 191213998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above. The Licensee and Staff 1 do not have a TB clearance on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Licensee will submit copies of the TB clearance for Licensee and Staff 1 to CCL by the POC due date of 5/23/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Rita Ramos
NAME OF LICENSING PROGRAM MANAGER:
Joe Katrdzhyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


LIC809 (FAS) - (06/04)
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