<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417251
Report Date: 09/18/2025
Date Signed: 09/18/2025 02:56:15 PM

Document Has Been Signed on 09/18/2025 02:56 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:AGAYBY FAMILY CHILD CAREFACILITY NUMBER:
197417251
ADMINISTRATOR/
DIRECTOR:		AGAYBY, GERMINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 237-5768
CITY:ENCINOSTATE: CAZIP CODE:
91316
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 5DATE:
09/18/2025
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Gehan Koos, Assistant and Germin Agayby, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/18/2025 at 11:55 AM, Licensing Program Analyst (LPA) Brittanee Cleveland and Licensing Program Manager (LPM) Raul Navarro arrived to conduct an unannounced annual inspection to the above facility. LPA identified self and met with Gihan Koos, Assistant to Licensee, because Licensee was not at the facility at the time of LPA and LPM’s arrival. The Licensee, Germin Agayby, arrived at 12:24 PM and guided LPM and LPA on a tour of the facility The family childcare home’s operation hours are Monday through Friday from 9:00 AM to 5:00 PM. Licensee observed five toddlers in care at the time of the inspection.

This is a one-story home which consists of 2 bedrooms, 1 bathrooms, kitchen/dining room, living room, and fenced backyard area. Per Licensee, areas off limits to the children and parents include 1 bedroom. There is an additional unit in the backyard, which Licensee states is for children’s play activities. Per licensee, first bedroom is used as the isolation room for children who become sick while in care. Licensee provides snacks for children.

Individuals who reside in the home were noted and discussed.

Licensee states there are no firearms stored in the home.

All areas identified on the facility sketch that are accessible to children were inspected for safety, comfort, and cleanliness. There is a telephone service via a cellphone this is used and stays at the facility during the hours of operation. There is central ventilation and heating. Safe toys, play equipment and materials were observed. Licensee stated that additional unit is only used for inside play activities and the children sleep and eat in the front house. The additional unit includes a storage closet and bathroom for children. -- Page 1

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Brittanee Cleveland
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2025
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 8
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)
Page: 2 of 8
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: AGAYBY FAMILY CHILD CARE
FACILITY NUMBER: 197417251
VISIT DATE: 09/18/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Disinfectants, cleaning solutions, medications and other items that are dangerous to children, were inaccessible to children. All poisons are locked in a cabinet in the kitchen area and is inaccessible to children. Carbon monoxide and smoke detectors were observed are operable. General sanitation was observed. LPA did not observe any walkers, baby bouncers, inclined chairs, baby saucers, or any similar items at the facility.

The valve on the required 3A 40BC fire extinguisher indicates fully charged and was purchased on July 2025, per the purchase receipt.

Licensee states that there is one infant who is 9 months enrolled. All children sleep in the front house. LPA and LPM observed play yards and changing tables for children. The play yard mats are covered in a fitted sheet with no loose or hanging items. LPA did not observe any infants that were swaddled. A sleep log was provided for the infant enrolled indicating signatures for infant being checked every 15 minutes.

For outside play time, children use the fenced backyard area. The play area was observed to be fenced. LPA observed outdoor toys and other materials children can play with, in good condition. LPA advised licensee that all equipment and fencing shall remain in good conditions for the safety of children.

Licensee and assistant were observed to be operating within capacity limitations. LPA did not observe any children left in parked vehicles. Car seats are only to be used for transportation. LPA did not observe any children sleeping in car seats.

The licensee and assistants have completed training for preventative health practices including pediatric first aid and CPR. The licensee’s CPR and pediatric first aid expires in May 2026. There are first aid supplies that were inspected by LPA. LPA advised licensee that when a child shows signs of illness, they shall be separated from other children.

Children’s records were reviewed, including emergency information and were observed to be complete. LPA did not observe immunization records, which are required for children’s records. This will result in a Type B violation that will need to be corrected by September 30, 2025. Deficiencies that cited need to be cleared to protect the children’s health and safety.

-- Page 2

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Brittanee Cleveland
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
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: AGAYBY FAMILY CHILD CARE
FACILITY NUMBER: 197417251
VISIT DATE: 09/18/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The licensee does have proof of immunizations against influenza, pertussis and measles. One of the assistant’s immunization records was not on file after review. This will result in a Type B violation that will need to be corrected by September 30, 2025. Deficiencies that cited need to be cleared to protect the children’s health and safety.

LPA observed that licensee does not have proof of the Mandated Reporter training and certificates are on file for assistants. This will result in a Type B violation that will need to be corrected by September 30, 2025.

All homes shall conduct fire and disaster drills at least ever once every six months and document the date for each drill. Licensee stated a fire/disaster drill was conducted on August 25th 2025, according to log

LPA did not observe any pets in the home.

LPA did not observe any bodies of water on the premises.

Emergency Disaster Plan, Parents Rights, and Facility License were observed to be posted.

Smoking is prohibited in a licensed family childcare home. Per licensee, no one smokes in the home.

Five Type B deficiencies were identified during the review of staff and children’s files. The deficiencies cited are based on the upkeep of staff and children’s records. These deficiencies shall be corrected by September 30, 2025 via email to LPA.

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 [or facility representative] 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. -- Page 3

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Brittanee Cleveland
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC809 (FAS) - (06/04)
Page: 4 of 8
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: AGAYBY FAMILY CHILD CARE
FACILITY NUMBER: 197417251
VISIT DATE: 09/18/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA discussed the safe sleep regulations with licensee [or facility representative] 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 [or facility representative] 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/.

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.

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.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Germin Agayby.

---- Page 4

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Brittanee Cleveland
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 09/18/2025 02:56 PM - It Cannot Be Edited


Created By: Brittanee Cleveland On 09/18/2025 at 02:39 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: AGAYBY FAMILY CHILD CARE
FACILITY NUMBER: 197417251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2025

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
1
2
3
4
Per Licensee, they will have staff submit proof of immunization and email a copy to LPA by the POC date of 09/30/25.
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review), the licensee did not comply with the section cited above in 3 out of 3 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
1
2
3
4
Per Licensee, they will email a copy of staff files to LPA by the POC date of 09/30/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Brittanee Cleveland
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 09/18/2025 02:56 PM - It Cannot Be Edited


Created By: Brittanee Cleveland On 09/18/2025 at 02:39 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: AGAYBY FAMILY CHILD CARE
FACILITY NUMBER: 197417251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 3 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
1
2
3
4
Per Licensee, they will send a copy of the Notice of Employee Rights via email to LPA by the POC date of 09/30/25.
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
1
2
3
4
Based onrecord review, the licensee did not comply with the section cited above in 3 out of 3 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
1
2
3
4
Per Licensee, they will submit proof of immunization for staff via email to LPA by the POC date of 09/30/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Brittanee Cleveland
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 09/18/2025 02:56 PM - It Cannot Be Edited


Created By: Brittanee Cleveland On 09/18/2025 at 02:39 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: AGAYBY FAMILY CHILD CARE
FACILITY NUMBER: 197417251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 child which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
1
2
3
4
Per Licensee, they will submit proof of immunization for child via email to LPA by the POC date of 09/30/25.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date: 09/18/2025
Plan of Correction
1
2
3
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.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Brittanee Cleveland
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2025


LIC809 (FAS) - (06/04)
Page: 8 of 8