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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700462
Report Date: 06/14/2022
Date Signed: 06/14/2022 04:30:57 PM

Document Has Been Signed on 06/14/2022 04:30 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: 8CENSUS: 4DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Yeritsyan TatevikTIME COMPLETED:
04:45 PM
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On 6/14/22 Licensing Program Analysts(LPAs)Barbara Beneroso and Isabel Ortega conducted an unannounced annual random inspection. The LPAs met with licensee who guided the LPAs on a tour of the facility. Upon entry to the facility the LPAs observed four children in care.
This is a single-story family home with 3 bedrooms, converted garage and 3 restrooms. Main care is provided in the permit converted garage referred to as the children's playroom area. The children utilize the bathroom located in the play room. The off-limits areas are the 3 bedrooms and 2 restrooms, and the entire main home is off limits, a child safety gate is at the entrance of the main home to prevent the children from accessing the remaining of the home.

The day care home provides breakfast, lunch, and dinner. The operating child care hours are Monday through Friday from 8:00 a.m. to 5:00 p.m.
The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. The knives are kept in the kitchen, cleaning chemicals and medication are stored inaccessible to children in care.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/14/2022 04:30 PM - It Cannot Be Edited


Created By: Isabel Ortega On 06/14/2022 at 02:48 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: YERITSYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, review, record review, 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: 06/15/2022
Plan of Correction
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According to licensee Assistant will no longer continue to provide care and supervision until assistant is fingerprinted, associated and cleared.
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:Carissa Bell
LICENSING EVALUATOR NAME:Isabel Ortega
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


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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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: YERITSYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700462
VISIT DATE: 06/14/2022
NARRATIVE
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The First Aid kit was observed and complete. The required fire extinguisher (2A10BC) is in reading in green. Smoke and carbon monoxide detectors are in operable condition (tested 1:57 P.M.). Fire and disaster drills are conducted every six months and logged last emergency drill was conducted 6/14/22 P.M. Pediatric CPR and First Aid certificate expires March 6, 2023. Licensee provided Mandated Reporter training certificate dated 5/21/21.

Licensee had all the required posted documents: Facility License (LIC 203, Notice of Parent's Rights Poster (PUB 394), Emergency Disaster Plan (LIC 610A), and Earthquake Preparedness Checklist (LIC 9148)


The LPAs observed a current child roster. Child files were found to be complete.

The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.

There are age appropriate toys and equipment on the premises. Per the licensee there are no weapons or firearms of any kind in the facility. The LPAs did not observe any weapons. There is pool on the premises with alarms on all exist windows and pool cover.

The licensee provided proof of immunization against pertussis (TDAP), measles (MMR), and influenza.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
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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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: YERITSYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700462
VISIT DATE: 06/14/2022
NARRATIVE
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The side yard is gated all around. The outdoor play area is free from debris. The following were discussed: No smoking, infant walkers, Johnny jumpers, exersaucers and any other item that falls into that category are permitted in the facility. The LPAs also discussed earthquake safety and necessity of drills, required forms for children’s files, facility files and posting requirements and penalty.

The licensee was informed that all adults living in or having access to the home are required to have fingerprint clearances with Department of Justice, FBI and Child Abuse Index prior to having contact with children. If the aforementioned is not adhered to, a Civil Penalty of up to $500, per non-cleared adult will be assessed immediately. Assistant is not fingerprint cleared Type A issued today.

The Licensee was reminded 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.

Safe Sleep regulations (infants 0- 24 months) were discussed, technical violation advisory was provided. Licensee referred to the CCL web site for additional information and PINS. LPA provided infant Care plan form LIC9227 and went over 15-minute check logs, infant safe sleep plan and safe sleep PIN.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
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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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: YERITSYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700462
VISIT DATE: 06/14/2022
NARRATIVE
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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.

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

Child Care Advocates:

To sign up for our Quarterly Updates please email the Child Care Advocates at


chilcareadvocatesprogram@dss.ca.gov & (916) 654-1541
The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
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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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: YERITSYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700462
VISIT DATE: 06/14/2022
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The following Type A deficiency was issued today for, Criminal Record Clearance 101170(e)(2). S1 was working at the facility without criminal record clearance.

Upon receipt of a Type A deficiency the licensee shall post the report for 30 days in addition to the Notice of Site Visit & provide copies of the licensing report to parents/guardians of children in care at the facility. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months & licensee will obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. If these requirements are not met, civil penalties will be assessed.



The facility was not found in compliance per Title 22 regulations, one deficiencies will be cited today. Technical advisories were provided as a preventative. An exit interview was conducted, a copy of this Report and a Notice of Site visit was provided to the licensee. Appeal rights were reviewed with licensee.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
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