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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495168
Report Date: 09/07/2022
Date Signed: 09/09/2022 03:00:11 PM

Document Has Been Signed on 09/09/2022 03:00 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:GRIGORYAN & KHECHIKYAN FAMILY CHILD CAREFACILITY NUMBER:
197495168
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
09/07/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gohar Grigoryan and Sofya KhechikyanTIME COMPLETED:
12:30 PM
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On 09/7/2022 Licensing Program Analyst (LPA) Judy Laureano conducted an announced inspection with applicants Gohar Grigoryan and Sofya Khechikyan for the purpose of a pre licensing inspection of 8014 Andasol Avenue, Northridge, CA 91325. The purpose of this inspection is to ensure the standards for a Family Child Care Home are being met in accordance to California Tittle 22 Regulations and California Health and Safety Codes.

The licensees are applying for a Small Family Child Care Home license for a max capacity of 8. Per the application, at this time, the ages the applicants wish to provide services for are children 3 months old to 13 years old with the hours of Monday- Saturday 7:00 a.m. to 12:00 a.m. Licensee was informed that any changes to ages, hours and days of operation shall be submitted to the department for approval prior to initiation of changes. Applicants will be available for evening and infant care.

The applicant is the leasing the property and a copy of lease/rental agreement and Landlord Consent is on file. Currently living in the home is the two applicants and a minor grand daughter.

The home is a single family unit with 3 bedrooms with 2 bathroom, ½ bathroom, living room, dining room, kitchen, and attach garage. The home was observed to have an enclosed front yard and back yard. Applicants confirmed the front gate will remain locked and a ring camera/door bell will be installed.

Parents will access the home through the main entrance. Entering the home, you are led to the day care space. LPA observed by the entrance the Parent Board with all necessary posting required. The living room and dining room area were observed to have age appropriate toys. Children cubbies were observed across the main entrance, a children rug
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GRIGORYAN & KHECHIKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495168
VISIT DATE: 09/07/2022
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covered the area. Children size table and chairs were observed next to the kitchen play area. LPA observed children’s books and a mounted television set. A highchair and napping cots were observed in the space. Applicants confirmed that children will nap and eat in the area. Applicants confirmed the home has fire alarm system with sprinkle system installed in case of an emergency.

LPA observed licensee test the carbon monoxide and smoke detector in the area. All electrical outlets were observed to be covered in the living room, dining room and kitchen area. Smoke detector is located in the hallway of the home.

The bathroom that children will use was observed to be located across from the dining room area. The ½ bath was observed and inspected. Under the sink cabinet was observed to have a safety latch making the contents inaccessible to the children in care. LPA requested the electrical outlets to be covered and applicants provided covers to the outlets. LPA discussed COVID-19 recommendation such as using paper towels and displaying a handwashing sign for children to view.

The kitchen was observed and inspected. Applicants confirmed the kitchen area will be used as a walkway to access the backyard. All lower cabinets were inspected and observed to have safety latches, making the contents inaccessible to the children in care. Under the sink cabinet was observed to have cleaning supplies and LPA observed a safety latch, making the content inaccessible. All knives and sharp objects are stored in a drawer that was observed to have a safety latch making the items inaccessible. The stove was observed, and applicants confirmed that facility will be providing meals and snacks. LPA discuss food preparation, storage and ensuring a log and information regarding dietary restrictions and allergies are kept up to date. LPA referred applicants to their current Resource and Referral Agency for additional information regarding the Food Programs.

Outside the kitchen, a small hallway was observed that leads to the bedrooms. The hallway was observed to have a pantry like area. LPA observed a safety gate outside the pantry like area where the refrigerator and mounted fire extinguisher were observed.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
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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: GRIGORYAN & KHECHIKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495168
VISIT DATE: 09/07/2022
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Pass the safety gate, LPA observed the following area that has been designated as OFF LIMITS to the children in care. Applicants confirmed the safety gate will remain locked during hours and operations and the doors to each bedroom will remain locked during hours of operations.
Bedroom 1 was observed to have a sliding door that gives access to the backyard.
Bedroom 2 was observed to have a bathroom and a sliding door that leads to the backyard.
Bedroom 3 was observed to have a bathroom.

You are able to access the back yard through the kitchen area. The backdoor at the end of the kitchen gives access to the backyard. The backyard was observed to be cemented.
The sides of the home were observed to have a safety gate making both sides of the home inaccessible to the children in care. LPA observed a plastic climbing structure with soft landing pads to cushion children’s falls. LPA observed age appropriate outdoor toys and children’s size tables and chairs.

LPA provided applicants with a sample packet of Forms/Records to keep in your Family Child Care home as well as the LEAD Prevention flyer and Prohibited Items in Family Child Care Home Flyer.

No bodies or waters were observed in the space. The home does not have open face heaters or fireplaces. Applicants confirmed NO fire arms and/or ammunition are stored in the home.

The following areas are OFF LIMITS to the children in care:
Bedroom 1, bedroom 2 and bedroom 3- doors will remain locked during hours of operations.
Bathroom 2 and bathroom 3, located inside bedroom 2 and bedroom 3- doors will remain locked during hours of operations.
Garage- doors will remain locked during the hours of operations.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
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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: GRIGORYAN & KHECHIKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495168
VISIT DATE: 09/07/2022
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The following corrections need to be completed by September 13th, 2022.
1. Changing table needs to be assembled
2. Pack and Play or crib need to be purchased.

Exit interview was conducted, and report was reviewed with both applicants, Gohar Grigoryan and Sofya Khechikyan. The licensing determination of this application will be reviewed with Licensing Program Manager for final resolution.

The following was discussed with the applicant:
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

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.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
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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: GRIGORYAN & KHECHIKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495168
VISIT DATE: 09/07/2022
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LPA reviewed with applicants the LIC 311D, Forms/Records To Keep In Your Family Child Care Home, children’s forms/records, family forms/records, and information to be posted.
CHILDREN'S FORMS/RECORDS
Children's files must contain the following documents/information:
• Parent Notification, Additional Children in Care (LIC 9150), if you plan to care for more than 6 children for a Small Family Child Care Home, or more than 12 for a Large Family Child Care Home.
• Copy of document verifying child’s enrollment in Kindergarten or K-T. (22 CCR 102421(c)) • Affidavit Regarding Liability Insurance (LIC 282) - This form is required to be signed by each parent of a child in care if you do not have either liability insurance or a bond.
• Consent for Medical Treatment (LIC 627) - This document gives you permission by the parent to seek emergency medical or dental care for their child if needed.
• Consent/Verification for Nebulizer Care (LIC 9166) - Before a child care licensee or staff person can administer inhaled medication to a child in care, this form must be completed and filed in the child's record and in the personnel file. A separate form must be filled out for each person who administers inhaled medication to the child.
• Identification and Emergency Information (LIC 700) - This form must be kept for each child in care and identifies whom to call in an emergency.
• Notification of Parents' Rights (LIC 995A) - This form must be given to each parent at the time a child is accepted for care, along with the LIC 995E.
• Caregiver Background Check Process (LIC 995E) - This form must be given to each parent at the time a child is accepted for care, along with the LIC 995A.
• Family Child Care Consumer Awareness Information (LIC 9212) - This form must be given to the parents of each child in care.
• California School Immunization Record (PM 286) or Confirmation of required immunization for children not enrolled in a public or private elementary school - For every infant, toddler, or preschool age child admitted into a Family Child Care Home, the provider must maintain current immunization records. PM 286 can be downloaded from the following website: http://www.cdph.ca.gov NOTE: Personal beliefs statement no longer applies (2015 SB 277).
• Acknowledgement of Receipt of Licensing Reports (LIC 9224), if applicable.
• Blood Glucose Testing Consent (LIC 9222) Must be signed by parent prior to administering test.
• Individual Infant Sleeping Plan (LIC 9227) – Must be kept for infants up to 12 months of age.
• Sleep Logs – must be kept for infants up to 24 months of age.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
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: GRIGORYAN & KHECHIKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495168
VISIT DATE: 09/07/2022
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FACILITY FORMS/RECORDS
• Facility files must contain the following documents/information:
• Personnel Records as required in Title 22, Division 12, Chapter 3, Section 102416.1, including but not limited to, proof of current pediatric first aid, CPR and preventive health practices certificate, lead poisoning training, mandated reporter training (2015 AB 1207), TB test results, measles, pertussis and influenza/may decline influenza, and documentation of either a criminal record clearance or a criminal record exemption.
• Unusual Incident/Injury Report (LIC 624B) - You must use this form and submit it to your local licensing office when reporting any incidents or injuries occurring during day care hours.
• Child Care Facility Roster (LIC 9040) - It is required that each child care facility maintain a current roster of children who are provided care.
• Notice of Employee Rights (LIC 9052) - This form must be filled out by all employees working in the Family Child Care Home.
• Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108) -This form is the Child Care Custodian's acknowledgement of the requirement to report suspected child abuse.
• Property Owner/Landlord Consent Form (LIC 9149), if you plan to care for more than 6 children for a Small Family Child Care Home or more than 12 for a Large Family Child Care Home.
• Property Owner/Landlord Notification Form (LIC 9151).
• Proof of control of property, including but not limited to a copy of your deed, mortgage statement or property tax bill, or lease/rental agreement.
• Verification that fire drills and disaster drills are conducted every six months.
• Emergency Disaster Plan (LIC 610A) - Evidence satisfactory to the department that there is a fire escape and disaster plan for the facility and that fire drills and disaster drills will be conducted at least once every six months.
• Earthquake Preparedness Checklist (LIC 9148) or equivalent, must be attached to the LIC 610A and available to the public.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
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: GRIGORYAN & KHECHIKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495168
VISIT DATE: 09/07/2022
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INFORMATION TO BE POSTED IN YOUR FAMILY CHILD CARE HOME
You are required by law to post the following in your home:
• Facility Sketch (LIC 999A) or equivalent sketch
• Notification of Parents' Rights Poster (PUB 394) - This poster must be placed in an area of the home where all parents can see it.
• Facility License (LIC 203)-Your Family Child Care Home License must be posted in an area of the home where it can be easily seen.
• Notice of Site Visit (LIC 9213) must remain posted for 30 days (during the hours that children are in care) after each site visit by a licensing representative.
• Any licensing report documenting a type “A” citation must be posted for 30 days during the hours that children are in care.
• Any licensing report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

Licensee was made reminded that it is the licensee’s, 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.

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.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
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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: GRIGORYAN & KHECHIKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495168
VISIT DATE: 09/07/2022
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LPA discussed the safe sleep regulations with applicants 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 applicants 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.

Not providing: 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

Applicants were reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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 Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed.

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)
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
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: GRIGORYAN & KHECHIKYAN FAMILY CHILD CARE
FACILITY NUMBER: 197495168
VISIT DATE: 09/07/2022
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The fire extinguisher type 2A-10BC 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
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC809 (FAS) - (06/04)
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