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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417713
Report Date: 11/10/2021
Date Signed: 11/10/2021 03:09:34 PM

Document Has Been Signed on 11/10/2021 03:09 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:GEVORKYAN FAMILY CHILD CAREFACILITY NUMBER:
197417713
ADMINISTRATOR:GEVORKYAN, TERESAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 744-7230
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 9DATE:
11/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Tereza Gevorkyan, LicenseeTIME COMPLETED:
03:35 PM
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On 07/16/2021 Licensing Program Analyst (LPA), Shandra Powell conducted an unannounced Annual Required Inspection and was met by Licensee, Tereza Gevorkyan. Days and hours of operation are Monday thru Friday from 7am to 6pm.

LPA toured the home inside and outside and a census was taken. LPA observed 9 children in care with licensee and assistant (volunteer). LPA reviewed Guardian Website and Licensing Information System (LIS) and found assistant (volunteer) has no clearance of Live Scan nor did the assistant (volunteer) have immunization's available for LPA to review during inspection. This poses a immediate health and safety to children in care. LPA requested Licensee to asked assistant (volunteer) to leave facility until she has completed a criminal record clearance and is associated to the facility. LPA requested licensee to also have assistant (volunteer) to provide all required immunization's before returning to facility to work with children. Current facility sketch reviewed and Licensee confirmed that Living, Dining, attached Garage, Bathroom next to attached garage in hall way and Backyard are used for providing care and are accessible to children.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Shandra Powell
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GEVORKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197417713
VISIT DATE: 11/10/2021
NARRATIVE
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LPA advised licensee to place child proof lock on cabinet under kitchen sink, licensee provided lock on cabinet during inspection. LPA requested Licensee to call one of the children's parents due to the volunteer leaving home and 9 children were in attendance. The Family Child Care Home will have to revert back to a Small Licensed Child Care Home when only one Adult is present. Licensee agreed.

All other rooms are off-limits and made inaccessible by use of locked doors. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises.

All poisons are kept in a locked storage area in the kitchen. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

The fireplace located in the dining room is made inaccessible by a screen and non operable per licensee. LPA observed a fire extinguisher in the attached garage, however licensee stated it was serviced about a year ago. LPA advised licensee to either service fire extinguisher each year and or buy a new fire extinguisher each year. The smoke detector and carbon monoxide detector were observed and tested during inspection. The home has adequate heating and ventilation for safety and comfort. There are no stairs in this home.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Shandra Powell
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GEVORKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197417713
VISIT DATE: 11/10/2021
NARRATIVE
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Safe toys and play equipment were observed, however LPA observed a Baby Walker in home during inspection this is a potential health and safety risk to children in care. Licensee was asked to take baby walker out of home during inspection. The home has working telephone service and LPA confirmed the phone number is (818) 744-7230 (Cell Phone).

There are currently 2 infants in care. LPA discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing.

Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Shandra Powell
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GEVORKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197417713
VISIT DATE: 11/10/2021
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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 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.

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.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited with civil penalties: (see next page, 809 D)

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Shandra Powell
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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Page: 3 of 13
Document Has Been Signed on 11/10/2021 03:09 PM - It Cannot Be Edited


Created By: Shandra Powell On 11/10/2021 at 01:12 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: GEVORKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197417713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(10)
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: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2021
Plan of Correction
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Licensee will complete a declaration and remove baby walker today on the POC date of 11/10/21.
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2021
Plan of Correction
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Licensee will complete a declaration and release assistant from her duties until the assistant has completed and cleared a criminal record clearance and has been associated to the facility.
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:Karren Starks
LICENSING EVALUATOR NAME:Shandra Powell
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021


LIC809 (FAS) - (06/04)
Page: 8 of 13
Document Has Been Signed on 11/10/2021 03:09 PM - It Cannot Be Edited


Created By: Shandra Powell On 11/10/2021 at 01:12 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: GEVORKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197417713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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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4
Based on interview the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2021
Plan of Correction
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Declaration completed by licensee on POC date 11/10/21.
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.
SUPERVISOR'S NAME:Karren Starks
LICENSING EVALUATOR NAME:Shandra Powell
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021


LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 11/10/2021 03:09 PM - It Cannot Be Edited


Created By: Shandra Powell On 11/10/2021 at 01:12 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: GEVORKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197417713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2021
Plan of Correction
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Licensee will submit to LPA a copy of the LOG for Fire/Disaster which must be created by POC date 11/12/21 and emailed to LPA.
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

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 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2021
Plan of Correction
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Licensee will submit the created sleep log 15 min check to LPA by POC date 11/11/21 and email to LPA
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:Karren Starks
LICENSING EVALUATOR NAME:Shandra Powell
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021


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Page: 6 of 13
Document Has Been Signed on 11/10/2021 03:09 PM - It Cannot Be Edited


Created By: Shandra Powell On 11/10/2021 at 01:12 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: GEVORKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197417713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021

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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2
3
4
Based on interview and record review the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2021
Plan of Correction
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Licensee shall complete Mandated Reporter Training and email a copy of certificate to LPA by POC date 11/12/21.
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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Based on record review the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2021
Plan of Correction
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Licensee will complete a declaration with a list of the required immunizations needed for any employee and or volunteer.
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:Karren Starks
LICENSING EVALUATOR NAME:Shandra Powell
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021


LIC809 (FAS) - (06/04)
Page: 11 of 13
Document Has Been Signed on 11/10/2021 03:09 PM - It Cannot Be Edited


Created By: Shandra Powell On 11/10/2021 at 01:12 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: GEVORKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197417713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2021
Plan of Correction
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2
3
4
Licensee will email a copy of the completed LIC 9227 Sleeping Plan for all infants enrolled at facility to LPA by POC date of 11/11/21.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Karren Starks
LICENSING EVALUATOR NAME:Shandra Powell
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021


LIC809 (FAS) - (06/04)
Page: 5 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GEVORKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197417713
VISIT DATE: 11/10/2021
NARRATIVE
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Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. LPA reviewed children’s files and observed files were in- complete with emergency information as required. Licensee’s Mandated Reporter Training has not been completed. Licensee’s pediatric CPR/First Aid will expire on June 2023. Due to the licensee not completing the Mandated Reporter training the facility is out of compliance and Licensee was informed that she is a mandated child abuse reporter with the responsibility of reporting any suspected child abuse to the Child Abuse Hotline at (800) 540-4000.

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.



New Immunization Requirement: Law enacted by SB 277, beginning January 1, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into child care or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint.

Assembly Bill 1207 amended Penal Code Section 11165.7 and amended Health and Safety Code Section 1596.866 and added Health and Safety Code Section 1596.8662.
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 every two years. Volunteers are encouraged but not required to take the training.
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Shandra Powell
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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Page: 7 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GEVORKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197417713
VISIT DATE: 11/10/2021
NARRATIVE
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This training requirement may be directly met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/ and are provided in English and Spanish. If no training is made available in a required person’s primary language, then those persons shall be exempt from this requirement.

For additional information and forms visit our website at: www.ccld.ca.gov

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). 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 (English/Spanish).



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

Exit interview conducted and a copy of report and appeal rights were reviewed with Licensee.
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Shandra Powell
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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