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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195700271
Report Date: 09/24/2025
Date Signed: 09/24/2025 03:18:30 PM

Document Has Been Signed on 09/24/2025 03:18 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:KHACHATRYAN FAMILY CHILD CAREFACILITY NUMBER:
195700271
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 6CENSUS: 2DATE:
09/24/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:17 AM
MET WITH:Khachatur Khachatryan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 09/24/2025, Licensing Program Analyst (LPA) Dawn Dowling conducted an unannounced annual and capacity increase inspection at 257 West Linden Avenue, Burbank, CA 91502. LPA arrived at the facility 10:17 AM, identified self and met with Kaykuhi Manukyan, Assistant who indicated Licensee Khchatur Khachatryan was at the store and would be back shortly, there were 2 children present upon LPA's arrival.

License arrived at 10:32 AM, LPA gave Licensee the LIC 125- Entrance Checklist and business card. Licensee gave LPA a tour of the inside and outside of the home. The Hours of Operation are Monday through Friday 8:00 am to 5:30 pm and wants to have children ages 0 to 14 years of age in care.

The family child care home is one story home consisting of 3 bedrooms, 2 bathrooms, Living Room, Kitchen, Laundry Room, Den, Front Yard, Back yard that has a pool. The pool has been drained from all water has a gate surrounding it with a lock as well as a gate that is locked surrounding the entrance to the pool.

On 08/01/2025 LPA Dowling received an email from Burbank Fire Prevention Bureau with STD 850- Fire Safety Inspection record indicating that home has been granted a Fire Clearance on 08/01/2025 for capaciity of 14.The Children enter the child care home from the front door, living room is the primary child care room, has table and 7 chairs, in the den there is an additional table with 2 chairs.LPA observed the children will have access to bathroom #1 in the hallway near bedroom #1 and bedroom #2, Licensee wants to use Bedroom #1 as an additional child care room for watching Children TV Shows, music time or additional room for napping.

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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2025
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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700271
VISIT DATE: 09/24/2025
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The bathroom that is accessible to children in care was observed to have running water, toilet was operable, had soap and paper towels for washing hands, no hazards were observed, and the cabinet is secured with the use of a child proof latch. LPA observed that the bathroom that children will use was safe and sanitary.

Licensee confirmed that the living room, Bedroom #1 and #2, Bathroom#1, Backyard are areas to be used by children in care. Off limit area are : Bedroom#3- Licensee's Bedroom (made inaccessible by child proof lock), Bathroom #2, Front yard, Den, Kitchen and Laundry Room(Gate making area inaccessible to children in care).

There is a swimming pool on the premises, it does not have water in it at this time. Pool has a black self latching gate surrounding it with a lock on it, and then another White wooden gate that is kept locked and made inaccessible to children in care. Licensee reminded once he puts any water in the pool he has to ensure there is a Pool Cover that meets the performance standards of American Society of Testing and Materials (ASTM) international Standard F1346-23 as well as life ring with a minimum exterior diameter of 17 inches with a United States Coast Guard approval label, a rescue pole with a body hood and a minimum fixed length of 12 feet. Licensee was given Health and Safety Code Regulation 1596.814- Family day-care home; in ground swimming pool requirements to keep and be aware of regarding pool safety. Per Licensee there are no guns or ammunition on the premises. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible. There is a defunct fireplace in the living room and is made inaccessible with a white board that closes it off.

The fire extinguisher was purchased 08/01/2025. Smoke Detector and Carbon Monoxide were tested and operable. First Aid kit was complete. There is adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed.

The outdoor play area in the back yard is fenced and there are no hazards to children present. Licensee was reminded to wipe down toys prior to children using each day to ensure they are free from spider webs which could cause harm to children in care if not checked daily. Capacity as specified on the license is being maintained.

Licensee resides in home by himself, has an assistant when needed Kaykuhi Manukyan is fingerprint cleared.

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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700271
VISIT DATE: 09/24/2025
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LPA Dowling reviewed children’s files and observed files were complete with:

· LIC 282- Affidavit Regarding Liability Insurance


· LIC 700 Identification and Emergency Information
· LIC 627 Consent for Emergency Medical Treatment
· LIC 995A Notification of Parent's Rights
· Immunization Record
  • Infant Sleeping Chart for Infant Under 24 Months of Age

LPA Dowling observed following documents posted on bulletin board in living room accessible to parents:

· Facility License


· PUB 394- Notification of Parents Rights
· LIC 9148- Earthquake Preparedness
· LIC 610A- Emergency Disaster Plan
  • Earthquake Drill last conducted on 07/31/2025
  • Fire Drill last conducted on 05/23/2024
License provided LPA with the following documents:
  • Mandated Reporter Training Certificate taken 01/25/2024- Expires 1/2026
  • American Heart Association Pediatric First Aid/CPR/AED- Taken 01/27/2024-Expires 01/26
  • Immunization's for Tdap, Measles, Mumps, Rubella (MMR) and Negative TB results
  • Declination of Flu Shot

Assistant Kaykuhi Manukyan associated to the facility provided proof of the following:
  • American Heart Association Pediatric First Aid/CPR/AED- Taken on 04/19/2025- Expires 04/27
  • Immunization Record of Tdap, Measles, Mumps, Rubella (MMR) and Negative TB results
  • Declination of Flu Shot

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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700271
VISIT DATE: 09/24/2025
NARRATIVE
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Licensee provides meals and snacks for children in care. Licensee reminded that if children bring food from home to label and keep stored separate

LPA observed 1 play yard for children under 12 months of age in care and 9 Cots. 1 table in Living room with 7 chairs and 1 extra table in Den a. For the facility increase Licensee will need to have the following additional times for more children in care:

  • Licensee purchased an additional play yard for infants 12 months and under
  • 5 more cots of children 12 months or older
  • 5 additional chairs

Licensee purchased the additional items via Amazon while LPA was at visit. Licensee emailed LPA proof of purchases.

Licensee provides bedding for children in care, if a child has an accident the bedding is immediately removed and bedding is changed. Licensee washes bedding every week at the end of the week.

If a child is sick the isolation are is bedroom #1 in order to keep away from other children in care and wait for parent(s) to pick child up from care.

State law prohibits baby walkers, bouncy seats, exer-saucers and any other items that fall into that category. LPA did not observe any prohibit items in home.

Criminal Record Statement Family Child Care Homes

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.

Licensee is properly documenting 15 minute when child is sleeping. LPA Dowling informed Licensee to continue with documentation for any children 24 months and under that he may enrool to ensue that he continues to document infant every 15 minutes when sleeping, their breathing, temperature and color of skin should also be monitored.

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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700271
VISIT DATE: 09/24/2025
NARRATIVE
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 Licensee is properly documenting 15 minute when child is sleeping. LPA Dowling informed Licensee to continue with documentation for any children 24 months and under that he may enrool to ensue that he continues to document infant every 15 minutes when sleeping, their breathing, temperature and color of skin should also be monitored.

Safe Sleep regulation was discussed with licensee as well as the Child Care Licensing Safe Sleep web

page listed below that licensee can utilize as an additional resource.https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep

The licensee is advised to never shake a baby to prevent Shaken Baby Syndrome

Medication :

LPA discused medication with Licensee, Licensee does not give medication to children in care. LPA informed licensee if he does givse msedicasiton to children in care it is bet to have medication that has been prescribed by child's Doctor and it is to be kept separate with child's name and instructions for giving medication on the label. Licensee informed to ensure any and all Medication is inaccessible to children in care.

Incidental Medical Services (IMS) policy

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 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: http://www.ada.gov/childqanda.htm

LPA Dowling observed children in care were in caring and nurturing environment and treated with dignity and respect.

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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700271
VISIT DATE: 09/24/2025
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Licensee made corrections by purchasing additional items during LPA's visit and sent proof of proof of purchase to LPA 's email.

During todays visit Type B deficiencies was cited (see LIC 809Ds). Licensee given Technical Advisory for pool along with Pool Regulation should licensee decided to make pool operable by putting water into the pool.

The Licensee was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days.

Exit interview conducted with Licensee. A copy of this report, notice of site inspection, Appeal Rights (LIC 9058), were given and explained during LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/24/2025 03:18 PM - It Cannot Be Edited


Created By: Dawn Dowling On 09/24/2025 at 02:32 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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 195700271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(c)
Child's Records
(c) In any case in which the licensee cares for an additional child pursuant to Section 102416.5(b) for a Small Family Child Care Home or Section 102416.5(d) for a Large Family Child Care Home, the licensee shall maintain, in the child’s record, a copy of documentation verifying the child’s enrollment and attendance at kindergarten, including transitional kindergarten, or elementary school as required in Section 102416.5(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 3 children enrolled do not have proof of enrolment and attendance in school which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2025
Plan of Correction
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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.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Dawn Dowling
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2025


LIC809 (FAS) - (06/04)
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