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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700462
Report Date: 06/14/2021
Date Signed: 06/14/2021 02:42:13 PM

Document Has Been Signed on 06/14/2021 02:42 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:YERITSYAN FAMILY CHILD CAREFACILITY NUMBER:
197700462
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
06/14/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Tatevik YeritsyanTIME COMPLETED:
03:32 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 6/14/2021 at 1:30 p.m., Licensing Program Analysts (LPA) Isabel Ortega conducted an announced prelicensing inspection for a small Family Child Care Home. LPA was greeted by applicant, Tatevik Yeritsyan who guided the LPA on a tour of the facility.

Applicant will operate Monday through Friday: 7:30 a.m. to 5:00 p.m. The applicant will provide breakfast, snack, lunch, and dinner as needed. Applicant plans to enroll in a food nutrition program.



This is a one-story family unit which consist of four-bedroom, three bathrooms, a kitchen, dining room, living room, laundry room, den and four sheds located in the backyard. The den and bedroom #4 will be the primary location in which care is provided. Children will utilize the bathroom located to the left of the hallway by the entrance of the home. The back yard is divided into two sections. One side will be utilized for outside play (shaded area observed) and the other section is off limits (LPA observed a gate separating the yards). The off-limit areas include the bedroom#1, #2 and #3, the other two restroom, laundry room, kitchen. Dining room, living room, four sheds (maintained key locked, located in the back yard), and the second yard where the pool is located.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2021
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: YERITSYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700462
VISIT DATE: 06/14/2021
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 home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and center air ventilation. The home has age appropriate toys, play equipment and materials. Applicant stores sharp knives, medications in an inaccessible kitchen cabinet, located to the left of the sink and maintained closed with a child safety latch the kitchen is off limits and a child safety gate was observed at the kitchen opening by LPA. Applicant has a complete First Aid Kit in the home, which is stored inaccessible to children. Cleaning solutions and supplies are stored in the laundry room inaccessible to children (maintained locked). Children will be provided with cots and/or mats for nap time. There is a fire place which is barricaded by a locked screen.

There is a pool on the premises. Applicant submitted a declaration statement stating children will not be allowed to utilize the pool and pool gate will remain locked during the hours of operation. The pool area will not be utilized by the children in care (pool does not meet Title 22 requirements). Applicant was reminded about ensuring proper care and visual supervision at all times.



LPA observed a fire extinguisher (2A10BC) that meets the State Fire Marshal standards (reading in green). Applicant tested the smoke detector and carbon monoxide detector and they were found to be in operable condition. Home has central air conditioning and heating. Per the applicant, there are no weapons or firearms in the home, nor did LPA observe any weapons or firearms during the inspection.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: YERITSYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700462
VISIT DATE: 06/14/2021
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 applicant's Pediatric CPR/First Aid expires on 3/08/2023. The 8-hour Preventative Health and Safety Certification that includes Child Nutrition dated 6/1/2019 and Lead Poisoning Prevention was completed on 4/16/2021. The applicants had the required immunizations against pertussis (Tdap), measles (MMR), and tuberculosis (TB). The Mandated Reporter training was completed on 1/8/2021. Family Child Care Home Orientation certificate was provided. The Mandated Reporter Training was dated 5/26/2021.

Applicant will have the parent board and other Licensing required forms at the entrance of the home, visible to parents.

The following was discussed with applicants:
Mandatory licensing forms for the children’s files, facility forms/records, and information to be posted in the family child care home; Requirements to conduct fire and disaster drills once every six months and record it; Role and responsibilities of being a mandated reporter were reviewed; Applicant was made aware that it is her responsibility to know the regulations as well as anyone who assists in providing care; Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified; Regulation prohibits the smoking of any kind in the family child care home.

The applicants were informed that all adults living in or having access to the home, or employees are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Central Index prior to having contact or working with children. If the aforementioned is not adhered to, a Civil Penalty of up to $500, per non-cleared adult will be assessed immediately. Please advise your analyst of any person who will be visiting regularly or for longer than one week. The applicant was advised to utilize the Request for Live Scan Service form LIC9163 to have adults fingerprinted and associated to the home.

SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: YERITSYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700462
VISIT DATE: 06/14/2021
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 applicant was advised of the requirement to report Unusual Incidents. A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above. The applicant was informed to utilize the Unusual Incident Report/Injury Report form LIC624B when submitting the report to the department.

The applicant was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days whenever a licensing inspection is conducted. If a Type A deficiency is cited, a copy of the licensing report must also be posted for 30 days. The same report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and licensee must obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian and place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports (LIC 9224). If these requirements are not met civil penalties per violation will be assessed.

Beginning on January 1, 2018, Assembly Bill 1207 (2015) 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. Applicants must meet requirements as a precondition to licensure. New employees shall have 90 days from date of employment to complete training as required. The training may be conducted at the following website www.mandatedreporterca.com. This certificate is valid for two years.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: YERITSYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700462
VISIT DATE: 06/14/2021
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
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

The applicant was advised it is her responsibility to visit the department's website to access licensing forms, Quarterly Updates and Provider Information Notices (PINs): www.ccld.ca.gov

Child Care Advocates:
To sign up for our Quarterly Updates and Provider Information Notices (PINs), please subscribe online: http://www.cdss.ca.gov/inforesources/Community-Care-Licensing/subscribe

The following was provided to the applicants by via-mail: All licensing forms required in children's files; All licensing forms required in the facility; All licensing forms to be posted in the home; Fire and Disaster Drill log; California Car Seat Flyer; Safe Sleep Flyer; Parent Notification Requirements; and Safe Sleep in Child Care brochure; and additional resources for the applicant and her Family Child Care Home.



Applicant has met Title 22 regulations; the pool gate has been corrected and meets Title 22 regulations. Therefore, a Small Family Child Care Home License capacity of 8 children is granted effective today 6/14/2021.

An exit interview was conducted, and a copy of this report was provided to applicant 6/14/2021. All Licensing reports are recommended to be kept on file for minimum three years.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5