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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020852
Report Date: 10/11/2021
Date Signed: 10/11/2021 11:31:01 AM

Document Has Been Signed on 10/11/2021 11:31 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:KHACHATRYAN FAMILY CHILD CAREFACILITY NUMBER:
198020852
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
10/11/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Susanna Khachatryan, ApplicantTIME COMPLETED:
12:00 PM
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PRE LICENSING INSPECTION CONDUCTED IN ARMENIAN
Licensing Program Analyst (LPA) Anomeh Eivazian conducted an announced pre-licensing inspection to the above facility on 10/11/2021. LPA arrived at the facility at 8:20 AM and met with Susanna Khachatryan, Applicant who guided analyst on a tour of the facility. During this inspection applicant's daughter, Anna Khachatryan was also present. During this inspection individuals who reside in the home were discussed and notes on Confidential Name List (LIC811) and attached to this report. Per applicant operation hours will be Monday to Saturday, 7:00 a.m. to 6:00 p.m.. Applicant states she will care for children 0-12 years old.

All areas identified on the facility sketch were inspected. This is a one story home located on the first level. The home consists of 3 bedrooms, 2 restrooms, living room , dining room, kitchen, laundry room, converted detached garage, front yard and backyard (fenced). There is a fireplace in the living room which has been blocked off to prevent access to children. Per applicant, parents will enter the facility either through the side gate which leads the backyard and daycare room or main entrance.
Areas that are accessible to children are as follows: Living room, dining room, kitchen, laundry room, one bedroom, one bathroom in the hallway of laundry room, and front part of back yard (fenced).

Areas off limits based on facility sketch submitted to children and parents include: Two bedrooms, bathroom in the master bedroom, detached converted garage, front yard, and back of backyard.
**Rooms that are off-limits need to be made inaccessible during operating hours** The applicant does understand that licensing staff may have access to off-limit areas during inspection visit if necessary.

At 8: 45 am, the applicant began touring LPA’s through the home starting with the entry way which lead directly to the living room and dining room. The living room and dining room were inspected and electrical outlets were observed to be covered. LPA observed a dining table, chairs, sofas and a coffee table in the living room.
REPORT CONTINUES ON NEXT PAGE 1 of 5
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2021
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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020852
VISIT DATE: 10/11/2021
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There is a fireplace in the living room which has been blocked off to prevent access to children. Next to the living room, The kitchen was inspected, and LPA observed latches on the cabinets where the applicant stores cleaning compounds and sharp items. The medications and knives are stored in a cabinet out of reach for children. Next LPA toured the off-limit master bedroom and bathroom in the master bedroom and did not observe any hazards. LPA observed a plastic door knob on the master bedroom door knob. Next LPA toured the laundry room and one off-limit bedroom in the hallway and did not observe any hazards. Next LPA toured the bathroom in the hallway and did not observe any hazards. LPA observed safety latches on the cabinets under the sink and storage above the sink. Next LPA toured the last bedroom (daycare area) and observed children toys, tables, chairs, and napping cots in the daycare area. LPA observed applicant's family member personal belongings in the home. LPA observed the required 2A 10BC fire extinguisher was anchored to the wall in the laundry room. It was purchased on 07/20/21 as read by LPA from the receipt. Applicant tested the carbon monoxide detector in the laundry room and smoke detector in the kitchen. 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. There are emergency supplies available in the kitchen.

Next LPA toured the backyard fenced. Per applicant children will use the front part of backyard which is gated and separated from the rest of the off-limit area in the backyard. 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 outdoor playarea ground was concrete and artificial grass. The licensee states that supervision is always provided. Next LPA toured the off-limit back of backyard and detached converted garage and did not observe any hazards.


The applicant states that they 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 10:05 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 a landline 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. Applicant has proof of CPR and First Aid training as indicated on the certificate. The applicant does have proof of Health and Safety training (completion date: 07/10/2021), Pediatric First Aid and CPR (ex. 07/2023). The applicant has proof of immunization against influenza, pertussis, and measles. Applicant completed required mandated reporter training on 07/03/2021. Mandated reporter training must be completed every 2 years. www.mandatedreporterca.com
REPORT CONTINUES ON NEXT PAGE 2 of 5
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020852
VISIT DATE: 10/11/2021
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The following was discussed with the applicant:
Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.
-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.
-Smoking is prohibited in a family child care 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.
REPORT CONTINUES ON NEXT PAGE 3 of 5
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020852
VISIT DATE: 10/11/2021
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INFANT CARE: Applicant states that she cares for infants. Applicant states that infants will sleep in the living room, dining room and daycare bedroom where they are constantly be 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 can not 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.

SAFE SLEEP: LPA discussed the safe sleep regulations with applicant 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 .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: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: KHACHATRYAN FAMILY CHILD CARE
FACILITY NUMBER: 198020852
VISIT DATE: 10/11/2021
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During this inspection LPA discussed PIN 20-06 CCP, Social And Physical Distancing Guidance And Healthy Practices For Child Care Facilities In Response To The Global Coronavirus (COVID-19) Pandemic Written In Collaboration With The California Department Of Education and reviewed Child Care Covid-19 Self Assessment.

Per applicant, there are no dual licenses at this address. Applicant’s email address was obtained during this inspection. The applicant was advised that email may be public information. Per applicant, she does not carry liability insurance or a bond in accordance with standard established by Family Child Care statue. 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.


LPA consulted and explained Child Abuse Reporting, Effects of Lead Exposure Flyer, Updated Patent’s Rights Poster with Complaint Hotline information, Capacity Handout (Small & Large) was provided during this inspection. LPA advised the applicant how to access forms, regulations and quarterly updates, and Provider Information Notices (PIN) on the Child Care Licensing website at: www.ccld.ca.gov. LPA reviewed and issued the Forms/Records to Keep in Your Family Child Care Home (LIC 311D) and provided the following forms:
CHILDREN FORMS/RECORDS , FACILITY FORMS/RECORDS , INFORMATION TO BE POSTED IN YOUR FAMILY CHILD CARE HOME

LPA inquired into the applicant's practices related to COVID-19. Applicant stated that she practice hygiene such as hand washing with the children. Applicant has hand sanitizer available in the drop off area and inside her home. Applicant states they practice social distancing with children, applicant, staff, parents and children above 2 years old will wear masks all the times indoors. LPA reviewed Child Care Program Covid-19 Self Assessment with applicant during this inspection.

A small family child care 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, Susana Khachatryan at 12:00 p.m..
REPORT END 5 of 5
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5