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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017772
Report Date: 07/24/2023
Date Signed: 07/24/2023 03:37:29 PM

Document Has Been Signed on 07/24/2023 03:37 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:CHILINGARYAN FAMILY CHILD CAREFACILITY NUMBER:
198017772
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 7CENSUS: 7DATE:
07/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Gayane Chilingaryan, LicenseeTIME COMPLETED:
04:00 PM
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REQUIRED- 1 YEAR INSPECTION CONDUCTED IN ARMENIAN
Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced required 1- year inspection to the above facility on 07/24/2023. LPA arrived at the facility at 12:45 PM and met with Gayane Chilingaryan, Licensee who guided analyst on a tour of the facility. A COVID 19 risk assessment was conducted prior to entering the facility. Per licensee, Gayane Chilingaryan facility hours are Monday to Friday from 7:00 a.m. to 6:00 p.m. LPA provided a copy of Entrance Checklist—Family Child Care Home (LIC126) to licensee.

This is a one story located on the first level. The home consists of 2 bedrooms, 2 bathrooms, kitchen, dining room, living room (FIREPLACE: inaccessible), den, garage, front yard and backyard (fenced). The children use the living room (main daycare room), dining room, one bedroom adjacent to the living room (main daycare area), kitchen, bathroom in the hallway of bedrooms, bathroom in the den, and fenced backyard. Per licensee, areas off limits to children and parents include: 1 bedroom, front yard and garage. LPA did not observe any stairs in the home during this inspection. During this inspection individuals who reside in the home were discussed and notes on Confidential Name List (LIC811) and attached to this report. Per licensee, parents enter the home through the main entrance which leads to the living room. LPA observed licensee is using and added one bedroom and bathroom in the hallway to daycare areas prior to obtain approval from licensing.

Upon LPA's arrival to the facility there were total of 7 children present in the facility, 4 being infants and 3 being 2 to 3 years old. LPA observed 5 children were on the napping cots in the living room and two infants were playing on the carpet in the living room. The licensee was observed not to be operating within the licensed capacity and is exceeding the required limitations during this inspection which poses an immediate health, safety and personal right to children in care..
REPORT CONTINUES ON NEXT PAGE 1 of 5
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CHILINGARYAN FAMILY CHILD CARE
FACILITY NUMBER: 198017772
VISIT DATE: 07/24/2023
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All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. At 1:00 p.m., Licensee took this LPA on a tour of the home. LPA was toured through the interior starting with the living room (daycare classroom), LPA observed 5 children were napping on the cots in the living room and two infants were awake and playing on the carpet in the living room. LPA observed children toys, tables, chairs, and four high chairs in the living room. LPA observed two high chairs were reclined all the way to the back. LPA advised licensee, that children can not sleep or rest on the high chairs and high chairs can only be used for eating. LPA observed a child safety gate was installed to the living room to separate the dining room and kitchen. Next LPA toured the one daycare bedroom adjacent to the living room and observed children toys and two pack n'plays in the bedroom. Next LPA toured the one bathroom in the hallway and did not observe any hazards. LPA observed off-limit bedroom door was closed during this inspection. Next LPA toured the dining room and kitchen and did not observe any hazards. Next LPA toured the den and observed sofas in the den. Next LPA toured the bathroom in the den and did not observe any hazards. LPA observed all electrical outlets were covered in the daycare areas. Per licensee, children mainly use the living room, one bedroom, and bathroom in the hallway. LPA observed the required 2A 10BC fire extinguisher was placed in the kitchen. It was serviced on 03/17/23 as read by LPA from the service tag. Licensee tested the carbon monoxide and smoke detectors in the living room. Both sounded off the alarms and heard by LPA to be functional. Detergents, cleaning compounds, medications, and other items which could pose a danger to children were observed to be inaccessible to children.

Next LPA toured the backyard fenced. Currently, children are using the back yard for outdoor play time. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that can pose a danger to children on the outdoor yard. The licensee states that supervision is always provided.

Per licensee, she provides snack to the children in care. Licensee was advised that if food is brought from the children’s homes, all containers must be labeled with child’s name and properly stored or refrigerated. Per Licensee, at 1:30 p.m there are no weapons, firearms, pools, spas, hot tubs, fish ponds, or similar bodies of water on the premises. Per licensee, there is a dog on the premises, which is not accessible to the children.
REPORT CONTINUES ON NEXT PAGE 2 of 5
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
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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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CHILINGARYAN FAMILY CHILD CARE
FACILITY NUMBER: 198017772
VISIT DATE: 07/24/2023
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All adults present have obtained a criminal record clearance on Licensing Information System (LIS). Per licensee, currently she does not have assistant. Licensee 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.

The licensee has completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 04/2024. Licensee, Gayane Chilingaryan completed required mandated reporter training on 04/28/2022. There are first aid supplies available on the premises in the kitchen. LPA advised licensee that if a child shows signs of illness he/she/they shall be separated from other children.

At 1:40 p.m., facility roster was reviewed and not current and completed. Per licensee currently there are 7 children enrolled. LPA reviewed 7 children's records, including emergency information from 7 enrolled children, and all 7 reviewed files were completed. The licensee has proof of immunization against influenza, pertussis, and measles.

All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. Last drill documented was conducted on 05/10/2023.

Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted at the wall by the entrance. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that fall into these categories are not permitted in a family child care facility.

Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home. There is not telephone service available in the home during this inspection. Licensee, stated she uses her personal cellphone for daycare. Per licensee she does not carry liability insurance or a bond in accordance with standard established by Family Child Care statue. Signed statements (LIC282) on 7 reviewed files.
REPORT CONTINUES ON NEXT PAGE 3 of 5
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CHILINGARYAN FAMILY CHILD CARE
FACILITY NUMBER: 198017772
VISIT DATE: 07/24/2023
NARRATIVE
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INFANT CARE: Licensee states that she providing care for infants and during this inspection 4 infants were present in the home. Licensee states that infants sleep in the dining room and one bedroom where they are constantly supervised. Appropriate sleeping arrangements and cribs were observed. (one crib for each infant under one year old in care was observed). Cribs or play yard did not hinder the entrance or exit from the sleeping space, mattresses shall be firm and covered with a fitted sheet that overlaps the underside so it cannot be dislodged. Cribs and play yards were observed to be free of loose articles and objects. No objects were observed to be hanging above or attached to the side of the crib. LPA did not observe any infants swaddled while in care. LPA advised the Licensee that infants shall be placed on their backs for sleeping and shall be supervised. Infants shall be checked on every 15 minutes and the time of each 15-minute check shall be documented with child’s name and date. License did not have Infant Sleep Chart during this inspection. The LIC 9227 Individual Infant Sleeping Plan was not availalbe in infants up to 12 months of age files. A copy of the LIC 9227 was provided to Licensee. LPA provided the licensee with a copy of A Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. LPA also consulted and explained Child Abuse Reporting, Never Shake a Baby, and Safe Sleeping practices.

SAFE SLEEP: LPA discussed the safe sleep regulations with licensee, and discussed the Child Care Licensing Safe Sleep webpage at http://www.cdss.ca.gov/inforescources/child-care-licensing/public-information-and-resoucrces/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at http://www/cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Boppy recall: https://www.cpsc.gov/Recalls/2021/The-Boppy-Company-Recalls-Over-3-Million-Original-Newborn-Loungers-Boppy-Preferred-Newborn-Loungers-and-Pottery-Barn-Kids-Boppy-Newborn-Loungers-After-8-Infant-Deaths-Suffocation-Risk

Medication: Incidental Medical Services (IMS) policy was discussed. The licensee states that she will provide IMS. Per licensee, there are no children enrolled that require IMS at this time. 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.
REPORT CONTINUES ON NEXT PAGE 4 of 5
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CHILINGARYAN FAMILY CHILD CARE
FACILITY NUMBER: 198017772
VISIT DATE: 07/24/2023
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LPA advised the licensee to access forms, regulations and quarterly updates online at: www.ccld.ca.gov.

The following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

The Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

LPA Eivazian informed licensee, Gayane Chilingaryan that this report dated 07/24/23 documents 1 of Type A citation Type A citation which shall be posted for 30 consecutive days as there is/are immediate risks to the health, safety, or personal rights of children in care.

Also, LPA Eivazian informed the licensee, Gayane Chilingaryan to provide a copy of this licensing report dated 07/24/23 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardian for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experienced. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding inspection tools and methods, please visit the Program website at www.cdss.gov/inforesouces/community-care-liceinsing/inspection-process

Licensee, Gayane Chilingaryan was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.


During the exit interview, the Licensee, Gayane Chilingaryan, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
Exit interview conducted and report was reviewed with the Licensee, Gayane Chilingaryan at 4:00 PM.
REPORT END 5 of 5
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2023 03:37 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 07/24/2023 at 02:20 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CHILINGARYAN FAMILY CHILD CARE
FACILITY NUMBER: 198017772

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(a)
Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation on 07/24/23 the licensee did not comply with the section cited above and was operating out of ratio with one child, during this inspection there were total of 7 children present in the facility, 4 being infants and 3 being 2-3 years old, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2023
Plan of Correction
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Per licensee, effective 07/25/23, she will drop off one infant in order to have only 3 infants and 3 children age 2-3 years old in her daycare.
An updated facility roster and a written plan will be submitted to LPA by 07/25/23 via email.
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:Christina Gabelman
LICENSING EVALUATOR NAME:Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 07/24/2023 03:37 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 07/24/2023 at 02:20 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CHILINGARYAN FAMILY CHILD CARE
FACILITY NUMBER: 198017772

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(c)
Operation of A Family Child Care Home
(c) The home shall maintain telephone service.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on licensee currently she only use her personal cellphone for her daycare and there is no other telephone services available in the home, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Per licensee, she will have a telephone services available in the home by plan of correction due date.
Type B
Section Cited
CCR
102425(j)(2)(C)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Infants up to 12 month of age who are sleeping in a position other than on their back.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on licensee she has not completed Infant Sleep log for infants however check on the napping infants more often the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Per licensee, she will start to document every 15 minutes infants napping position, and check on them and document it.
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:Christina Gabelman
LICENSING EVALUATOR NAME:Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 07/24/2023 03:37 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 07/24/2023 at 02:20 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CHILINGARYAN FAMILY CHILD CARE
FACILITY NUMBER: 198017772

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation licensee added and using off-limit one bedroom and one bathroom in the hallway for daycare, prior to grant an approval from licensing department, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Per licensee, from now on if there should be any changes on the facility sketch, licensee will get an approval from licensing department prior to start using it. An updated facility sketch will be submitted to LPA.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on facility file review, the licensee did not comply with the section cited above and licensee did not have current facility roster available during this inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Per licensee, she will update the facility roster and a copy will be submitted to LPA.
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:Christina Gabelman
LICENSING EVALUATOR NAME:Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 07/24/2023 03:37 PM - It Cannot Be Edited


Created By: Anomeh Eivazian On 07/24/2023 at 02:20 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: CHILINGARYAN FAMILY CHILD CARE
FACILITY NUMBER: 198017772

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on children file review, the licensee did not comply with the section cited above and two infants 12 months old did have LIC 9227 in their files which poses/posed a potential health, safety or personal rights risk to persons in care.
LPA provided a copy of Infant Sleeping Plan LIC 9227 to licensee during this inspection.
POC Due Date: 08/24/2023
Plan of Correction
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2
3
4
Per licensee, she will have Infant Sleeping Plan LIC 9227 in infants age up to 12 months old by due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Christina Gabelman
LICENSING EVALUATOR NAME:Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023


LIC809 (FAS) - (06/04)
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