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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198021455
Report Date: 04/08/2024
Date Signed: 04/08/2024 10:12:24 AM

Document Has Been Signed on 04/08/2024 10:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:GRIGORYAN FAMILY CHILD CAREFACILITY NUMBER:
198021455
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
04/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Adrine GrigoryanTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Shushanik Safaryan conducted an announced pre-licensing inspection to the above facility on 04/08/2024. LPA arrived at the facility at 8:00 AM and met with Adrine Grigoryan, Applicant who guided analyst on a tour of the facility. During the visit licensees mother in law and licensees minor child were present too . Pre-licensing Entrance Checklist (LIC9280) was provided to applicant on 04/08/2024. During this inspection individuals who reside in the home were discussed and notes on Confidential Name List (LIC811) and attached to this report. A COVID 19 risk assessment was conducted prior to entering the facility. Per applicant operation hours will be Monday to Friday 7:00 am. to 07:00 PM. Applicant states she will care for children 0-13 years old.
All areas identified on the facility sketch were inspected. This is a one story house consists of 3 bedrooms, 2 bathrooms, living room, dining room , kitchen, guest house, storage area .

Areas that are accessible to children are as follows: Dining Room (play area), 1 bathroom located next to the playroom , 1 bedroom and backyard .

Areas off limits based on facility sketch submitted to children and parents include: Two bedrooms, bathroom in the hallway , living room, kitchen, part of the backyard, storage area , guest house .
**Rooms that are off-limits need to be made inaccessible during operating hours**
At 08:15 am, the applicant began touring LPA through the home starting with the side entry way which leads directly to the dining room(playroom ), bedroom. Rooms were inspected , licensee was reminded to cover all electrical outlets . LPA observed toys , chairs and cots for sleeping .Per licensee bedroom will be used for sleeping . Page 1 of 6

SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GRIGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021455
VISIT DATE: 04/08/2024
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Next to the playroom is the bathroom for children`s use . LPA toured the children’s bathroom and observed latch on the cabinet under the sink. LPA did not observe accessible hazards. Licensee showed LPA the cabinet in the restroom is secured. LPA observed the required 2A 10BC fire extinguisher was anchored to the wall in the play area . It was purchased on 03/06/2024 as read by LPA from the receipt. Applicant tested the carbon monoxide and smoke detectors in the hallway. It 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. LPA observed door that leads to the living room , kitchen, and licensees’ bedrooms . Per Licensee she will add child safety latch to the door to block children`s access to the off-limit areas . Next LPA toured the outdoor area . LPA observed toys , artificial grass. Per licensee children will be under supervision all the time when play outside .(Declaration Obtained ). Outdoor area was gated preventing access to the storage area and guest house which will off limit to children in care .(Declaration Obtained ) LPA observed latch on the doors from both sides . LPA did not observe any objects that can pose a danger to children on the outdoor yard.

Because the applicant leases the home proof of landlord notification is required. The LPA observed the Property Owner Notification form (LIC9151) that the applicant confirms was provided to the property owner. The applicant obtained a signed Property Owner Consent form (LIC 9149).




The applicant states that she will provide food for children in care. Applicant 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 applicant, at 09:00 am, there are no pets, weapons, firearms or bodies of water on the premises. There are toys available for children. There is telephone service via landline that is used at the facility during operation hours. LPA advised applicant that if a child shows signs of illness, he/she/they shall be separated from other children. Per applicant no one smokes in the home. There is first aid kit located in the play area. page 2 of 6
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GRIGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021455
VISIT DATE: 04/08/2024
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Applicant has proof of CPR and First Aid training as indicated on the certificate The applicant does have proof of Health and Safety training, Pediatric First Aid and CPR with expiration date 06/2025. The applicant has proof of immunization against influenza, pertussis, and measles.
Applicant completed required mandated reporter training on 02/04/2024. Mandated reporter training must be completed every 2 years. www.mandatedreporterca.com
The following was discussed with the applicant:
Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

-In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.


-A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.
-Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License shall be terminated.
-The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should check, and batteries replaced as needed.
-Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
-Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. (Use LIC624B for written report)
-Fire and safety drills must be performed every six months and documented for review by the Department.
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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GRIGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021455
VISIT DATE: 04/08/2024
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-Smoking is prohibited in a family childcare home.
-Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
-Dog(s) and or pets are recommended to be isolated from children in care.

-No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.
-All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
- Applicant shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.
- Emergency Disaster Plan, Parent’s Rights Poster and the Facility License are required to be posted.

INFANT CARE: Applicant states that she will care for infants. Applicant states that infants will sleep in the playroom where they are constantly supervised. Appropriate sleeping arrangements and cribs will be available once an infant being enrolled. LPA informed one crib for each infant in care will be needed. Cribs or play yard shall 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 shall be free of loose articles and objects. No objects shall be hanging above or attached to the side of the crib. LPA informed Applicant infants cannot be swaddled while in care. LPA advised the Applicant 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. The LIC 9227 Individual Infant Sleeping Plan shall be completed for each infant up to 12 months of age. A copy of the LIC 9227 was provided to Applicant. LPA provided the Applicant 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. page 4 of 6
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GRIGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021455
VISIT DATE: 04/08/2024
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SAFE SLEEP: LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
Medication: 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
Applicant’s email address was obtained during this inspection. The applicant was advised that email may be public information.

Per applicant, she will purchase liability insurance or a bond in accordance with standard established by Family Child Care statue otherwise signed statements (LIC282) will be on children’s files. The law requires Family Child Care provider to carry liability insurance or bond in the amount of $300,000 annually or to maintain the signed statement in the facility file. Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication. Page 5 of 6

SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: GRIGORYAN FAMILY CHILD CARE
FACILITY NUMBER: 198021455
VISIT DATE: 04/08/2024
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Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

MyChildCarePlan.org--Child Care Centers and Family Child Care Home Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California

LPA reviewed with applicant the LIC 311D, Forms/Records to Keep in Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

The following corrections need to be corrected prior to obtaining a small family childcare license. Corrections are due by 04/20/2024.

1. Applicant will cover all electric outlets in the playroom .


2. Applicant will add child safety knob to the door that leads to the living room to prevent children’s access to the off-limit areas .
A small family childcare license will be granted upon receipt of proof of corrections for the above. Once licensed, the applicant is required to adhere to the terms and limitations stated on the license.
The applicant’s signature on this report acknowledges that they have signed the Application for a Family Child Care Home License (LIC 279) under the penalty of perjury that the statements on the application and any attachments are correct.
Exit interview conducted and report was reviewed with the applicant, Adrine Grigoryan on 04/08/2024.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
LIC809 (FAS) - (06/04)
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