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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495155
Report Date: 12/07/2022
Date Signed: 12/07/2022 12:38:27 PM

Document Has Been Signed on 12/07/2022 12:38 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:AVETISYAN FAMILY CHILD CAREFACILITY NUMBER:
197495155
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
12/07/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH: Azatuhi AvetisyanTIME COMPLETED:
12:37 PM
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On December 7, 2022, Licensing Program Analyst (LPA) Doris Whitmore conducted an announced inspection with applicant Azatuhi Avetisyan for the purpose of a pre-licensing inspection of 8627 Langdon Avenue North Hills, CA 91343. The purpose of this inspection is to ensure the standards for a Family Child Care Home are being met in accordance with California Title 22 Regulations and California Health and Safety Codes. LPA met with Azatuhi Family Child Care who guided a tour of the inside and outside of the home. Currently living in the home is the Applicant’s husband and two small children ages 1 and 3 years old.

The applicant is applying for a small family childcare license with a max of 8. Property-owner/landlord consent (LIC9151) currently on file. The licensee is currently the only one living in the home. Per the applicant, currently the ages the applicant wishes to provide services to children are year 1yr to 6 years old and the hours of operation are Monday- Friday from 8:00a.m. to 5:00 p.m. Applicant was informed that any changes to ages, hours, days of operation shall be submitted to the department for approval prior.

The home is a one-story home with three bedrooms, two1/2 bathrooms, livingroom, dining room, laundry room, patio, pool, & two -car garage. The off limits will be 2 bedrooms, kitchen, &2 bathrooms. laundry room, patio, pool, two-car garage. The main day care will be in the living room Parents will access the home from the front gate. Parents will push the ring button and applicant will open the gate for parents to enter. Once parents enter the gate they will walk straight ahead to the front door. LPA observed to the right the Parents Board with the following documents posted, Emergency Disaster Plan, Earthquake Preparedness, Facility Sketch, Daily Schedule, Notification of Parents Rights., & Menu.

LPA observed in the dining room one long table with six white chairs. The Main Day Care will be in the living room. LPA observed one couch, a table, one small wooden table with 8 colorful chairs, carpet, easel with magnetic alphabets, books, counting board, all toys were age appropriate. LPA observed one highchair. LPA and applicant tested a fire alarm in the hallway at the time of the inspection there was no Carbon Monoxide. A white First Aid Kit was observed and had an Emergency First Aid Guide. LPA observed a Fire Extinguisher 2-A:10 BC. Page 1

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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 6
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: AVETISYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495155
VISIT DATE: 12/07/2022
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In the living room there is a fireplace with a black screen around it. From the living room there is a sliding door with a white latch that is locked to enter to the Patio. Once the sliding door is open there is notification that says living room sliding door. From the outside once you go out the sliding door the door can’t be locked from the outside and there is no notification.

The Patio Area, which is off-limits LPA, observed a refrigerator, couch, table, with six chairs and a kitchen area, refrigerator, trampoline. There is a swimming pool on the premises The swimming has a black mesh gate all around. In order to open the gate, you will have to push up. LPA observed once the gate is open it does swing away from the pool. On the side of the house there is two white safety gates. From the inside the sliding door does have a lock once your outside there is no lock for the sliding door.

All electrical outlets were covered. Next to the Living room the kitchen was observed. Kitchen is off limits to the children in care. A safety gate was observed making the kitchen inaccessible. Kitchen cabinets were observed to have white safety latches. The stove, refrigerator, sink counter area were observed and inspected. Knifes and sharp objects were observed to be made inaccessible to the children in care. LPA observed safety knobs on the stove Applicant confirmed that the facility will provide breakfast, snack, & lunch. In the Kitchen there is door which will remain locked at all times is the Laundry Room. LPA observed one washer and dryer. There is one bathroom to the right with only one toilet and one sink. There is another door which leads to the side of the house. Before entering to go outside there is a black bar door. Once you are on the side of the house there is another door that is locked to enter into the garage.

The home was inspected for safety, cleanliness, telephone service, inaccessibility to poisons, detergents, cleaning compounds, medicines, hazardous items that can pose a danger to children. From the living room to the left is a hallway that has four white storage spaces with safety locks at the top. In the storage space LPA observed diapers, towels, To the left is the bedroom which will be on limits. LPA observed a bed, cots, with sheets, a with more toys, and books. Next to the bedroom is the guest bedroom to have one bed and a closet. The bathroom that the children will be using did id not have toxins. The last bedroom was the Master Bedroom that had one bathroom.

Applicant was made aware of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on childcare licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541


Email Address: childcareadvocatesprogram@dss.ca.gov
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SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
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: AVETISYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495155
VISIT DATE: 12/07/2022
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Immunizations: Commencing September 1, 2016, SB 792, prohibits a person from being employed or volunteering at a childcare 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 inspection. Mandated Reporter Training: Beginning on January 1, 2018, AB 1207, 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. Website: www.mandatedreporterca.com. Licensee was reminded of their responsibility to report suspected child abuse.

Mandatory Forms for the children’s files and provider’s files were discussed. Applicant was referred to LIC 311D: Records To Keep in Your Family Child Care

. FORMS TO BE POSTED

LIC203 Facility License


LIC 610A Emergency Disaster Plan
LIC 9148 Earthquake Preparedness Checklist
PUB394 Notification of Parents Rights Poster
Children’s Records Requirements:
LIC 700 Identification and Emergency Information
LIC 627 Consent for Emergency Medical Treatment
LIC 282 Affidavit Regarding Liability Insurance
LIC 9150 Parent Notification Additional Children in Care
LIC 9166 Consent/Verification for Nebulizer Care
CDPH 286 (Immunization Blue Card) with Immunization record
PUB 72- Family Child Care Consumer Guide
LIC 995A Notification of Parent’s Rights
LIC 995E Caregiver Background Check Process
LIC 9212 Family Child Care Consumer Awareness Information
PM 286 California School Immunization Record (blue card)-http://www.dhs.ca.gov/publications/forms/immunization.htm
LIC 9224 Acknowledgement of Receipt of Licensing Report, if applicable.
Facility Records:
LIC 624B Unusual Incident/Injury Report
LIC 9040 Child Care Facility Roster
LIC 9052 Employee Rights,
LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
LIC 9149 Landlord Consent Form, if you plan to care for more than 6 for Small or 12 for Large
LIC 9151 Property Owner/Landlord Notification Form
Personnel Records as required in Tittle 22, Division 12, Chapter 3, Section 102416.1, including but not limited to proof of current pediatric CPR and First Aid Certificates, Preventative Health certificate and criminal record information.
 Page 3
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: AVETISYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495155
VISIT DATE: 12/07/2022
NARRATIVE
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Facility Records:
LIC 624B Unusual Incident/Injury Report
LIC 9040 Child Care Facility Roster
LIC 9052 Employee Rights,
LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
LIC 9149 Landlord Consent Form, if you plan to care for more than 6 for Small or 12 for Large
LIC 9151 Property Owner/Landlord Notification Form
Personnel Records as required in Tittle 22, Division 12, Chapter 3, Section 102416.1, including but not limited to proof of current pediatric CPR and First Aid Certificates, Preventative Health certificate and criminal record information.
 Proof of immunizations against pertussis (TDAP), measles (MMR), and influenza
Mandated Reporter certificate – www.mandated reporterca.com – renewed every two years.

Licensee was made reminded that it is the licensees, as well as anyone who assists in providing care responsibility to know the regulations. Licensee was also encouraged to read the Child Care quarterly updates every season as they come out to stay informed of any changes or updates to statutes and regulations.

Applicant was advised that regulation prohibits the smoking of tobacco in a private residence licensed as a family childcare home during the hours of operation.



Applicant was made aware that state law prohibits baby walkers, bouncy seats, exer-saucers and any other items that fall into that category. Applicant was also reminded that only children who are eating may be in highchairs and that car seats are utilized only for transportation.

LPA discussed the safe sleep regulations with applicant [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

Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep

LPA also informed applicant [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.

Page 4

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: AVETISYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495155
VISIT DATE: 12/07/2022
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This facility plans not to provide Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

Applicant was also informed that the provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome.
 Applicant 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.

· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.

· A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.

· Annual fees must be paid promptly and by the due date or a late fee shall be assessed, and/or the License shall be terminated. (If paying by check please make sure to write facility number on check to ensure that payment is applied to your facility number)

· The fire extinguisher must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries should be replaced.

· Changes should be reported the to the Department as soon as they occur such as construction and remodeling, telephone number changes and/or if you move from home.

· Reporting requirements: Applicant must report any unusual incident or injuries to the Child Care Regional office by telephone within 24 hours and in writing within 7 days. Applicant was provided with LIC 624 as a reference.

  • Fire and safety drills must be performed every six months and documented for review by the Department.

· All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

· LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov Page 5

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: AVETISYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495155
VISIT DATE: 12/07/2022
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  • Fire and safety drills must be performed every six months and documented for review by the Department.

· All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

· LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

Prior to licensure the following will need to be corrected:

Carbon Monoxide

Provide Changing Table for Infants

Cubbies

Ensure that children are safe have in place an alternative if there is No Notification that the says living room sliding door once door opens

Sliding door to lock from the outside

Safety Measure or Safety Gate in place where there is no direct access to the pool from the sliding door.

Exit interview was conducted, and a copy of the report was given to the applicant The applicant will have until December 23, 2022 to submit all corrections needed.

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SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC809 (FAS) - (06/04)
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