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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494006
Report Date: 11/17/2021
Date Signed: 11/17/2021 02:17:51 PM

Document Has Been Signed on 11/17/2021 02:17 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:DERTLYAN FAMILY CHILD CAREFACILITY NUMBER:
197494006
ADMINISTRATOR:DERTLYAN, KARINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 489-4898
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
11/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:KARINE DERTLYANTIME COMPLETED:
02:30 PM
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On 11/17/2021 Licensing Program Analyst (LPA) Loyce Phillips, conducted an unannounced Annual Required Inspection and was met by Licensee, Karine Dertlyan. Also present were 1 staff member and Licensee adult son. All adults present have criminal record clearance. Days and hours of operation are Monday through Friday from 8:00am to 5:00pm.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed and Licensee confirmed that the living room, dining room, din and bathroom #1 and #2 are used for providing care and are accessible to children. All the bedrooms, kitchen and attached garage are off-limits and made inaccessible by use of a safety gate for kitchen and locks on the bedrooms and garage 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 the garage. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

The fireplace is located in the living room is made inaccessible by safety locks.]There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (818) 489-4898.

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. The outdoor play area is in the backyard completely fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.
SUPERVISORS NAME: Peter Flores
LICENSING EVALUATOR NAME: Loyce Phillips
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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: DERTLYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494006
VISIT DATE: 11/17/2021
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LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on 3/22/2021 Licensee’s pediatric CPR/First Aid expires on 11/15/2022. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

Incidental Medical Services (IMS) policy was discussed. 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

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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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.
SUPERVISORS NAME: Peter Flores
LICENSING EVALUATOR NAME: Loyce Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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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: DERTLYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494006
VISIT DATE: 11/17/2021
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To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited: (see next page 809 D) Licensee was provided a copy of their appeal rights. no deficiencies are cited.

An exit interview was conducted , a copy of this report was read and provided to the Licensee, Karine Dertlyan. This report shall be me made available to the public upon request. LIC 9213 Notice of Site Visit was provided and required to be posted for 30 days.
SUPERVISORS NAME: Peter Flores
LICENSING EVALUATOR NAME: Loyce Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/17/2021 02:17 PM - It Cannot Be Edited


Created By: Loyce Phillips On 11/17/2021 at 02:03 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: DERTLYAN FAMILY CHILD CARE
FACILITY NUMBER: 197494006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021

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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Based on LPA's observation of a file review and Licensee statement. Licensee was unable to provide proof of immunization against Pertussis for Staff 2, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2021
Plan of Correction
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Licensee will provide proof of immunization of Staff 2, to LPA by email, fax or mail by POC date 11/29/2021.
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.
SUPERVISOR'S NAME:Peter Flores
LICENSING EVALUATOR NAME:Loyce Phillips
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2021


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