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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020796
Report Date: 04/12/2024
Date Signed: 04/12/2024 02:48:09 PM

Document Has Been Signed on 04/12/2024 02:48 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:FAZILIAN FAMILY CHILD CAREFACILITY NUMBER:
198020796
ADMINISTRATOR/
DIRECTOR:		TAMAR A. FAZILIANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 818-3027
CITY:GLENDALESTATE: CAZIP CODE:
91208
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 5DATE:
04/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Tamar Fazilian, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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CASE-MANAGEMENT INCIDENT INSPECTION CONDUCTED IN ARMENIAN
Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced case management inspection on 04/12/24, at 1:00 PM, due to an incident that occurred on Wednesday, 04/03/24. Upon LPA’s arrival to the facility Licensee, Tamara Fazilian was not present in the home. LPA met with Marine Mkrtchyan, licensee’s assistant who guided analyst on a tour of the facility. Shortly after, at 1:10 PM licensee arrived to the facility who stated she was at a training with Pacific Clinic Head Start Program. During this inspection LPA observed five children were present in the facility, three being infants napping in the daycare area. Licensee is affiliated with Pacific Clinic Head Start program.

Alleged Incident took place on Wednesday 04/03/24. Incident was reported via email next working day. Original LIC 624 Unusual Incident/Injury Report form was received by the Department within 7 days. The written incident report was received by email on Thursday 04/04/24. The facility reported the incident within the required 24 hour time frame.

LPA observed the area where alleged incident took place. LPA conducted interviews with staff#1 and staff#2. LPA obtained a copy of Pacific Clinic Head Start incident report. Child#1 X-ray report dated 04/03/24.

Per staff#1 and staff#2 interviews, who witnessed the incident, child #1 was playing outdoor on 04/03/24 on outdoor play structure. Approximately at 11:15 AM, Child#1 climbed up the slide, but then instead of sliding down from the slide, child#1 jumped off on the artificial grass area on left wrist. Per staff#1 and staff#2, child#1 after fall started crying, and complaining of pain in left forearm. Ice was applied, parent of child#1 was contacted. Child#1 was picked up at 11:30 AM and taken to the doctor. Per staff#2, child#1 sustained left forearm fracture. They placed a temporary cast on child#1’s left forearm and referred the child#1 to
REPORT CONTINUES ON NEXT PAGE 1 of 2
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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: FAZILIAN FAMILY CHILD CARE
FACILITY NUMBER: 198020796
VISIT DATE: 04/12/2024
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specialist. The specialist replaced the cast on 04/08/24. The new cast goes from the child’s palm to above the child’s elbow. The cast will stay on for 6 weeks. Per staff#1, she was standing by the slide and observed how the incident occurred, however it happened so quick that staff#1 was not able to prevent the fall.

Per staff#1 and staff#2, on 04/03/24 there were 10 or 11 children present in the facility with licensee and her assistant.

Ratio and staffing were in accordance with Title 22 Code of Regulations at the time of the incident.



LPA issued the Confidential Names List (LIC 811) to the licensee during this inspection. The Confidential Names List documents the staff and children involved with the incidents documented in this report.

At this time, there is not a preponderance of evidence that shows that the facility was in violation with Title 22 Regulations when these incident occurred. Therefore, there are no deficiencies being cited on this date.

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.

Exit interview conducted and report was reviewed with the Licensee, Tamara Fazilian at 3:00 p.m..


REPORT END 2 OF 2
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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