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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700683
Report Date: 02/02/2023
Date Signed: 02/02/2023 12:06:48 PM

Document Has Been Signed on 02/02/2023 12:06 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:SIMONYAN FAMILY CHILD CAREFACILITY NUMBER:
197700683
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
02/02/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Ashken SimonyanTIME COMPLETED:
11:59 AM
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On 2/02/2023, Licensing Program Analyst (LPA)Isabel Ortega conducted an announced prelicensing inspection for the purpose of conducting Family Child Care Home pre-licensing inspection for a Small Family Child Care. LPA was greeted by applicant, who guided the LPA on a tour of the facility.

Applicant will operate Monday through Friday from 7:00 a.m. to 6:00 p.m. The Applicant will provide breakfast, morning snack, lunch, afternoon snack and dinner as needed. Applicant plans to enroll in a Food Nutrition program.



This is a one-story family home which consist of three bedrooms, two restrooms, a kitchen, dining room, living room, attached garage and back yard. The dinning room will be the primary location in which care is provided referred to as the Child Care Play area. Children will utilize the restroom located to the left from the main entrance of the day care. Bedroom #2 will be utilized for an isolation area if a child begins to develop illness. The off-limit areas master bedroom #1 and bedroom #3(maintained locked with a child safety knob) and attached garage (key locked). The back yard is gated all around and enclosed.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700683
VISIT DATE: 02/02/2023
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The home was inspected inside and out for safety, comfort, cleanliness, service, heating and center air ventilation. The home has age appropriate toys, play equipment and materials. Applicant stores sharp knives in a kitchen drawer (LPA observed a child safety latch), medication is stored inaccessible to children. Cleaning supplies are stored underneath the kitchen sink (child safety latch observed). Applicant has a complete First Aid Kit in the home, which is stored inaccessible to children. Children will be provided with cots and infants will be provided with a crib for nap time.

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 at 9:45 a.m. and they were found to be in operable condition. Per applicant, there are no weapons or firearms in the home, nor did LPA observe any weapons or firearms during the inspection. There is a jacuzzi in the back yard with cover and inaccessible to children.



The applicant’s Pediatric CPR/First Aid expires on 11/17/2024. The applicant had the required immunizations against pertussis (Tdap), measles (MMR), and tuberculosis (TB). Family Child Care Orientation was completed 10/13/2022. Preventative Health and Safety training with lead and nutrition component is dated 11/19/2022. Child Care Provider Mandated Reporter training is dated 11/17/22.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700683
VISIT DATE: 02/02/2023
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Licensee will have the parent board and other Licensing required forms at the entrance of the day care, visible to parents.

The following was discussed with applicants:
Infant safe sleep PIN, Infant Safe Sleep Plan(LIC9227) and safe sleep log were provided.

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; Licensee 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 Licensee was 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: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700683
VISIT DATE: 02/02/2023
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The Licensee 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 Licensee 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.
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700683
VISIT DATE: 02/02/2023
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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. This certificate is valid for two years.

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 licensee 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
SUPERVISORS NAME: Lady King
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SIMONYAN FAMILY CHILD CARE
FACILITY NUMBER: 197700683
VISIT DATE: 02/02/2023
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Child Care Advocates:
To sign up for our Quarterly Updates and Provider Information Notices (PINs), please subscribe online: www.ccldca.gov http://www.cdss.ca.gov/inforesources/Community-Care-Licensing/subscribe

The following was provided to the licensee: 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; 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 is ready for licensure, applicant did has met Title 22 regulations a Small Family Child Care Home License with a child care capacity of 8 children will be granted today 2/2/20223.

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

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6