198021455-4-14-2025-33-CC-POCA-DFLPRW-20250410113326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198021455
Report Date: 04/10/2025
Date Signed: 04/14/2025 11:09:00 AM

Document Has Been Signed on 04/14/2025 11:09 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 CARE		FACILITY NUMBER:	198021455
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 6	CENSUS: 5	DATE:	04/10/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Licensee, Adrine Grigoryan		TIME VISIT/ INSPECTION COMPLETED:	11:50 AM

NARRATIVE

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On April 10, 2025, at 8:50 am Licensing Program Analysts (LPA) Priscilla Ochoa conducted an unannounced annual inspection at the above facility. LPA was greeted by Licensee, Adrine Grigoryan who guided LPA on a tour of the facility. S2 was also present for the inspected but remained in an off-limits area. Per licensee there are 6 children enrolled and LPA observed 5 children in care. Hours of operation are Monday – Friday from 7:00 am – 12 am.

Family members residing in the home are 4 adults who obtain criminal record clearance along with 3 minor children. This is a single-story home that consist of 3 bedrooms, 2 bathrooms, living room, dining room, kitchen, detached garage, front yard and backyard (fenced).

Off limit areas include 2 bedrooms, 1 bathroom, kitchen, living room, front yard and detached garage.

Areas accessible to children in care are dining room (main day care area), 1 bathroom in the dining room, 1 bedroom in dining room and back yard (fenced).

At 9:15 am, licensee guided LPA on a tour of the facility. Per licensee, parents enter to through the side gate through the driveway, which leads them to the dining room. Upon entrance through the gate, LPA inspected the dining room which is the main day care area. LPA observed several age-appropriate toys for children in care, along with children’s cubbies to store personal items. LPA was then guided to the bathroom that is accessible to children in care, which located right next to the entrance of the dining room from the driveway. The bathroom was observed to be clean and orderly. LPA did not observe any hazardous materials that can pose a danger to children in care.

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NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 04/14/2025 11:09 AM - It Cannot Be Edited

Created By: Priscilla Ochoa On 04/10/2025 at 10:54 AM

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: GRIGORYAN FAMILY CHILD CARE	FACILITY NUMBER: 198021455
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1596.871(c)(1)(A)

Administration of Child Day Care Licensing

Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 3 staff did not obtain criminal record clearnce, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/10/2025
	Plan of Correction
1 2 3 4	LPA observed S3 leave the premise. Licensee understood that S3 cannot return to the facility until criminal record clearance is obtained.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

	Ana Chico
NAME OF LICENSING PROGRAM MANAGER:

	Priscilla Ochoa
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/14/2025 11:09 AM - It Cannot Be Edited

Created By: Priscilla Ochoa On 04/10/2025 at 10:54 AM

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: GRIGORYAN FAMILY CHILD CARE	FACILITY NUMBER: 198021455
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(7)

Operation of A Family Child Care Home

(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 4 out of 5 children did not obtain Consent of Emergency Medical Treatment (LIC 627) in their file for LPA to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	Licensee will ensure LIC 627 is completed by each child's representative and send a copy to LPA by poc date of 4/14/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

	Ana Chico
NAME OF LICENSING PROGRAM MANAGER:

	Priscilla Ochoa
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

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: 04/10/2025

NARRATIVE

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Bedroom 1 was then inspected, which is used as the napping area. LPA observed napping equipment in the form of cots. Bedding was observed to be clean, orderly, and stored properly. Per licensee, bedding and blankets are washed at the facility weekly. The back yard was then inspected, and LPA observed several age-appropriate toys for children in care. LPA also observed the detached garage to be separated from the back yard by a gate, which was locked. Per licensee, the gate and the detached garage is always locked making it inaccessible to children in care. All areas were observed to be clean, orderly, comfortable, and well ventilated. The licensee is observed to be operating within the license capacity limitations.

There are first aid supplies available. Per licensee, the facility provides all meals for children in care. LPA reminded the licensee that food brought from home must be labeled with the child’s name, stored properly and or refrigerated.

If a child becomes ill, the child is isolated in the bedroom that is in the dining room while the parents are called. A cot is available if needed.

Licensee's poisons, detergent, cleaning compounds, medications and other items which could pose a danger to child are stored where they are inaccessible to children.

LPA observed a functioning smoke detector in the dining room and a functioning carbon monoxide detector in the kitchen area. LPA observed a 2A-10BC fire extinguisher anchored in the dining room. The valve on the fire extinguisher was pointing to the fully charged green section. The licensee provided LPA a purchased receipt of 03/14/2025. There is a working telephone on site. Per Title 22 Emergency Disaster Drill must be conducted at least every 6 months. LPA observed the last Emergency Disaster Drill was conducted and documented on 12/17/2024.

Per the licensee, there are no weapons, pets or bodies of water on the premises. Licensee obtains a current Pediatric First Aid and CPR certification which expires on 06/10/2025.

LPA conducted a children file review and deemed not complete. C1 – C4 were missing Consent of Emergency Medical Treatment (LIC 627) in their file for LPA to review. LPA provided the licensee a copy for LIC 627.

LPA conducted staff file review and deemed not complete. During the tour of the facility S3 arrived to the dining room. LPA explained to licensee that S3 does not obtain Criminal Record clearance. Per Guardian clearance sheet, S3 is still in process. Per licensee S3 just started working at the facility as of 4/09/2025 and has submitted all of the paperwork.

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NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

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: 04/10/2025

NARRATIVE

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LPA explained to the licensee that when an adult appearance in process that does not mean that the adult is cleared to be on the premise during daycare hours. LPA called a Guardian representative to confirm the status of S3 and was advised that there was a hold on the application due to additional information being required. LPA explained the additional information that is needed for S3 in order for S3’s application to be processed and cleared. LPA observed S3 leave the premise. Licensee understood that S3 cannot return to the facility until criminal record clearance is obtained.

Licensee has completed mandated reporter training which expires 02/04/2026. All childcare employees must complete mandated reporter training within 30 days of hire and renew training every two years at

Licensee has the required documents posted in the FCCH; Facility License (LIC 203), Notification of Parents' Rights Poster (PUB 394) and Earthquake preparedness Checklist.

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

Licensee was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC624B. The on Duty Worker is available for questions Monday through Friday at (323) 981-3350 from 8:00 AM - 5:00 PM.

The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000. Also call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).

The licensee was informed that the presence of adults in the home without Criminal Record Clearance or Exemption will be cited and civil penalty assessed for $100 per day. The licensee may find additional information and forms on the DSS website at www.ccld.ca.gov including information on the Live Scan application (LIC 9163). Appointments can be made for Live Scan at 1-800-315-4507

The following was discussed with the licensee:Capacity requirements, Roster requirements, Posting requirements, Documentation requirements for disaster drills (fire and earthquake).

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NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

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: 04/10/2025

NARRATIVE

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Mandatory Forms for the children’s files and provider’s files, and Safe Sleep Awareness. The role and responsibilities of being a mandated reporter were reviewed. Licensee was reminded that supervision is always required to children in care.

Licensee was made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care. Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility’s phone number; if the phone number is changed, licensing must be notified.

Regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category.

--Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.

-- Our Quarterly updates come out every 3 months they are also now in Spanish please log in to the CCLD website or you can email our advocates to have the quarterly updates send directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee [or facility representative] 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.

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

Per licensee there are no Registered Sex Offenders living in the facility.

LPA provided consultation during inspection.

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NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

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: 04/10/2025

NARRATIVE

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LPA P. Ochoa informed licensee Adrine Grigoryan that this report dated April 10, 2025 documents 1 Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA P. Ochoa informed the licensee Adrine Grigoryan to provide a copy of this licensing report dated April 10, 2025 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/guardians 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. The facility is also being cited a type B citation on the attached LIC 809D (deficiency page) in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health and safety.

A notice of site visit was given and must remain posted for 30 days during facility’s hours of operation. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

An exit interview was conducted, and a copy of the report was provided to licensee Adrine Grigoryan.

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NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Priscilla Ochoa
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

LIC809 (FAS) - (06/04)

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