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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197409052
Report Date: 08/05/2024
Date Signed: 08/05/2024 04:03:04 PM

Document Has Been Signed on 08/05/2024 04:03 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:GROZOV FAMILY CHILD CAREFACILITY NUMBER:
197409052
ADMINISTRATOR/
DIRECTOR:		GROZOV, EDITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 727-1255
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 2DATE:
08/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Edita Grozov, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 08/05/2024 at 01: 15 PM, Licensing Program Analyst (LPA) Elicia Calvillo conducted a Case Management -Deficiencies Visit LPA identified self and met with Edita Grozov, Licensee, who allowed entry into the facility and provided LPA a guided tour of the inside and outside of the facility Upon arrival there were 2 children and no staff present.

Licensee informed LPA that effective 05/22/2024, Adult #3 (A3 )is employed as an assistant and currently works part time. Upon record review, Adult # 3 is missing the following items.

Current Pediatric CPR and First Aid Certification
LIC 9052 Employee Rights
Proof of Immunization: measles, pertussis, influenza (document of exemption)
TB Clearance or risk assessment
LIC 9108 Statement of Acknowledging Requirement to report Child Abuse
Mandated Reporter Training Certificate

The following deficiencies listed on the attached LIC 809D are being cited in accordance with California Code of Regulations Title 22.

The Notice of Site Visit (LIC 9213) must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.



Exit interview was conducted with Edita Grozov, Licensee including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Elicia Calvillo
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024
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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Document Has Been Signed on 08/05/2024 04:03 PM - It Cannot Be Edited


Created By: Elicia Calvillo On 08/05/2024 at 03:34 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GROZOV FAMILY CHILD CARE
FACILITY NUMBER: 197409052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2024
Section Cited
CCR
102416.1(a)

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102416.1 Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:
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Licensee stated they will provide LPA with the personnel records for Adult #3 by the plan of correction due date 08/23/2024
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This requirement is not met as evidenced by: Licensee did not have the personnel record for Adult #3 readily availabe for LPA to review during facility visit.
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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:Rita Ramos
LICENSING EVALUATOR NAME:Elicia Calvillo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024


LIC809 (FAS) - (06/04)
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