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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191501069
Report Date: 12/17/2021
Date Signed: 12/20/2021 08:37:39 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2021 and conducted by Evaluator Betty Bell
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20210928163425
FACILITY NAME:SAN MARINO COMMUNITY CHURCHFACILITY NUMBER:
191501069
ADMINISTRATOR:JIHAN MOUSSAUDFACILITY TYPE:
850
ADDRESS:1750 VIRGINIA RDTELEPHONE:
(626) 282-4186
CITY:SAN MARINOSTATE: CAZIP CODE:
91108
CAPACITY:75CENSUS: 0DATE:
12/17/2021
UNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Director Jihan MassoudTIME COMPLETED:
06:35 PM
ALLEGATION(S):
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Child sustained injuries while in care

Staff did not report child's injuries to child's authorized person

Staff did not provide a safe environment for children
INVESTIGATION FINDINGS:
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An unannounced, in person follow up Complaint inspection was conducted by Licensing Program Analyst (LPA) Emiko Bell on 12/17/21. Upon arrival, LPA was greeted and let into the facility by Director Jihan Massoud, who then guided LPA into her office and to whom the purpose of the inspection was announced. The purpose of the inspection was to provide the findings of the Complaint investigation.

Throughout the duration of the inspection, LPA Bell and Director Jihan Massoud wore face coverings as a COVID-19 precautionary measure. The COVID-19 screening questions were asked and answered.

Census: There were no children or staff present during the inspection.

Throughout the course of the investigation, interviews were conducted with six staff and eight parents; documentation in the form of the Child Care Facility Roster, three “First Aid Reports,” one “Confidential Observation,” form LIC 9163 “Request for Live Scan Service-Community Care Licensing,” a “DOJ applicant

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 12
Control Number 33-CC-20210928163425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SAN MARINO COMMUNITY CHURCH
FACILITY NUMBER: 191501069
VISIT DATE: 12/17/2021
NARRATIVE
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fingerprint response,” and two “Teacher Agreements” were obtained.



-Pertaining to the allegation that “Child sustained injuries while in care”:

According to the Reporting Party (RP), on 09/23/21, their four-year-old daughter in Room 2 fell very hard over a stack of chairs in the hallway between classrooms 4 and 5, sustaining a small bruise on her back from the fall.

According to the three “First Aid Reports,” the one child injured on 09/23/21 was a male who sustained a bump on his shin while climbing up a slide outside. According to the Child Care Facility Roster, there were no four-year-old females enrolled in Room 2 on 09/23/21.

According to the six staff interviewed, five stated that they were not aware of any children getting injured on the chairs; one staff stated that it would be surprising that a child got injured on the chairs, as staff are usually good at telling the children to go in a straight line and go around the chairs; two of the staff stated that they themselves had bumped into the chairs, while one staff stated that they may have heard of two children passing in the hallway and bumping into the chairs.

As of 09/23/21, there were 13 female children who are age 4 enrolled in the Center. Of these 13, interviews were conducted with the parents of eight of them. Of the eight parents interviewed, five parents stated that their daughters had not sustained injuries since the beginning of the school year. Of the remaining three parents, one parent stated that their daughter may have fallen over something, but could not recall what, and did not want to discuss it more as it "was not a big deal"; of the remaining two parents, one stated that their daughter had sustained an

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 12
Control Number 33-CC-20210928163425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SAN MARINO COMMUNITY CHURCH
FACILITY NUMBER: 191501069
VISIT DATE: 12/17/2021
NARRATIVE
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injury, but that she had hit her head; the other stated that their daughter may have sustained injuries two to three times, once hitting her head and once scraping her hand. However, the parent stated that the hand scraped may have just been their daughter’s hands being dry and moreover, could not recall whether the two to three injuries occurred during the summer or school year.

As two staff stated that they themselves had bumped into the chairs, one staff stated that they may have heard of two children passing in the hallway and bumping into the chairs, as one parent stated that their daughter may have fallen over something, and two others stated that their daughter may have sustained an injury, but were not sure whether it had occurred during the summer or school year, it could not be determined that on 09/23/21, a four-year-old female fell very hard over a stack of chairs in the hallway, sustaining a small bruise on her back from the fall.

There were no corroborating statements made to support the allegation. But as three parents stated that their daughters had sustained injuries and they may have occurred since the beginning of the school year, the allegation has been determined to Unsubstantiated.

This agency has investigated the complaint alleging that “Child sustained injuries while in care” and that there was a violation of Title 22, Division 12, Chapter 1, Article 6, Section 101223 Personal Rights. Based upon the evidence as presented above, the allegation has been determined to be Unsubstantiated. A finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies are being cited for the allegation listed above.

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 12
Control Number 33-CC-20210928163425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SAN MARINO COMMUNITY CHURCH
FACILITY NUMBER: 191501069
VISIT DATE: 12/17/2021
NARRATIVE
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-Pertaining to the allegation that “Staff did not report child's injuries to child's authorized person”:

According to the RP, on 09/23/21, their four-year-old daughter in Room 2 fell very hard over a stack of chairs in the hallway between classrooms 4 and 5, sustaining a small bruise on her back from the fall. RP states that they were not notified of their daughter’s injuries by staff and found out only when their daughter disclosed the incident at pick up time.

According to the three “First Aid Reports,” the one child injured on 09/23/21 was a male who sustained a bump on his shin while climbing up a slide outside. According to the Child Care Facility Roster, there were no four-year-old females enrolled in Room 2 on 09/23/21.

According to the six staff interviewed, five stated that they were not aware of any children getting injured on the chairs and that no parents had brought to their attention any incident where a child fell over the chairs and sustained injuries; though one staff stated that they may have heard of two children passing in the hallway and bumping into the chairs.

As of 09/23/21, there were 13 female children who are age 4 enrolled in the Center. Of these 13, interviews were conducted with the parents of eight of them. Of the eight parents interviewed, five parents stated that their daughters had not sustained injuries since the beginning of the school year. Of the remaining three parents, one parent stated that their daughter may have fallen over something, but could not recall what, and did not and did not want to discuss it more as it "was not a big deal"; of the remaining two parents, one stated that their daughter had sustained an injury, but that she had hit her head, though they not notified of the injury until their daughter told them, they sent an email, and then received a “note” the following day.

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
Page: 12 of 12
Control Number 33-CC-20210928163425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SAN MARINO COMMUNITY CHURCH
FACILITY NUMBER: 191501069
VISIT DATE: 12/17/2021
NARRATIVE
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LPA has the “First Aid Report” pertaining to this child; it states that the child ”got a bloody nose” in the classroom on 09/14/21. The other parent stated that their daughter may have sustained injuries two to three times, once hitting her head and once scraping her hand. However, the parent stated that the hand scraped may have just been their daughter’s hands being dry and moreover, could not recall whether the two to three injuries occurred during the summer or school year.

There were no corroborating statements made to support the allegation that “Staff did not report child's injuries to child's authorized person” since it could not be determined that there was a female child enrolled in Room 2 who sustained a bruise on their back after falling over a stack of chairs and whose teacher then did not report the incident to the child’s parents.

But as three parents stated that their daughters had sustained injuries and one parent stated that they were not notified until the following day after their daughter had notified them of hitting her head and after having then sent an email to the Center (though this may have been the 09/14/21 incident when a child sustained a bloody nose), the allegation has been determined to Unsubstantiated.

This agency has investigated the complaint alleging that “Staff did not report child's injuries to child's authorized person” and that there was a violation of Title 22, Division 12, Chapter 1, Article 6, Section 101212 Reporting Requirements. Based upon the evidence as presented above, the allegation has been determined to be Unsubstantiated. A finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 12
Control Number 33-CC-20210928163425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SAN MARINO COMMUNITY CHURCH
FACILITY NUMBER: 191501069
VISIT DATE: 12/17/2021
NARRATIVE
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No deficiencies are being cited for the allegation listed above.

-Pertaining to the allegation that “Staff did not provide a safe environment for children”:

According to the RP, on 09/23/21, their four-year-old daughter in Room 2 fell very hard over a stack of chairs in the hallway between classrooms 4 and 5, sustaining a small bruise on her back from the fall. The RP states that on 09/24/21, they observed chairs stacked on both sides of the restrooms in the hallway, which is approximately four feet wide.

According to Staff #1, the week of 09/07/21, they moved some of the chairs from the hallway to out in front of room 4. A couple days after, the chairs disappeared. As the custodian had been asked to put the chairs in the attic, S1 had assumed the custodian had. S1 again observed the chairs in the hallway on 09/13/21 but did not ask the custodian to remove them and did not check again since then to verify whether they had been removed.

On 10/01/21, LPA took photos of the stack of chairs in the hallway between rooms 4 and 5. The chairs were observed to be in one stack on the west side of the hallway, which indicates that the chairs had been moved since RP had observed them.

Though chairs stacked in a hallway are not necessarily safe, if chairs are stacked in a hallway, this alone cannot determine that an environment is unsafe. Of the three “First aid reports” obtained of injuries which had occurred from 09/13/21-10/01/21, none of them had to do with the chairs in the hallway. Further, according to the six staff interviewed, five stated that they were not aware of any children getting injured on the chairs while one staff stated that it would be surprising that a child got injured on the chairs, as staff are usually good at telling the children

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 12
Control Number 33-CC-20210928163425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SAN MARINO COMMUNITY CHURCH
FACILITY NUMBER: 191501069
VISIT DATE: 12/17/2021
NARRATIVE
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to "go" in a straight line and go around the chairs. Though two staff stated that they themselves had bumped into the chairs and that two children “may have” bumped into the chairs while passing in the hallway, no children were injured nor did any parents or staff deem the chairs hazardous enough to bring the chairs to the Director or any of the other Administration’s attention. Also, as the stack of chairs is about two feet high, in order to “fall over” them, the child would have to be an extremely tall child. And as children from Room 2 normally do not go in the hallway between rooms 4 and 5 for any reason since they do not play on the playground by rooms 4 and 5, and as no staff observed or was aware of a child falling over the stack of chairs, it may be less of a matter of the Center providing a “safe environment” as much as a lack of supervision. A child from room 2 would have to walk all the way down the corridor, enter the classroom, go to the hallway and fall over the chairs unobserved or heard by any staff in the hallway or any of the classrooms for at least five minutes in order to make this trek.

As no corroborating statements could be made that the chairs created an unsafe environment, the allegation has been determined to Unsubstantiated.

This agency has investigated the complaint alleging that “Staff did not provide a safe environment for children” and that there was a violation of Title 22, Division 12, Chapter 1, Article 7, Section 1012138 Buildings and Grounds. Based upon the evidence as presented above, the allegation has been determined to be Unsubstantiated. A finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.



No deficiencies are being cited for the allegation listed above.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
Page: 11 of 12
Control Number 33-CC-20210928163425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SAN MARINO COMMUNITY CHURCH
FACILITY NUMBER: 191501069
VISIT DATE: 12/17/2021
NARRATIVE
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An exit interview has been conducted with, and a copy of this report has been signed by and provided to Director Jihan Massoud. Appeal Rights were provided and explained to same.

The Notice of Site Visit was posted by Director Jihan Massoud in LPA's presence. The Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required will result in the issuance of a citation and the assessment of a $100 civil penalty.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
Page: 10 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2021 and conducted by Evaluator Betty Bell
COMPLAINT CONTROL NUMBER: 33-CC-20210928163425

FACILITY NAME:SAN MARINO COMMUNITY CHURCHFACILITY NUMBER:
191501069
ADMINISTRATOR:JIHAN MOUSSAUDFACILITY TYPE:
850
ADDRESS:1750 VIRGINIA RDTELEPHONE:
(626) 282-4186
CITY:SAN MARINOSTATE: CAZIP CODE:
91108
CAPACITY:75CENSUS: 0DATE:
12/17/2021
UNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Director Jihan MassoudTIME COMPLETED:
06:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Unfingerprinted staff are supervising children
INVESTIGATION FINDINGS:
1
2
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5
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7
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10
11
12
13
An unannounced, in person follow up Complaint inspection was conducted by Licensing Program Analyst (LPA) Emiko Bell on 12/17/21. Upon arrival, LPA was greeted and let into the facility by Director Jihan Massoud, who then guided LPA into her office and to whom the purpose of the inspection was announced. The purpose of the inspection was to provide the findings of the Complaint investigation.

Throughout the duration of the inspection, LPA Bell and Director Jihan Massoud wore face coverings as a COVID-19 precautionary measure. The COVID-19 screening questions were asked and answered.

Census: There were no children or staff present during the inspection.

Throughout the course of the investigation, interviews were conducted with six staff and eight parents; documentation in the form of the Child Care Facility Roster, three “First Aid Reports,” one “Confidential Observation,” form LIC 9163 “Request for Live Scan Service-Community Care Licensing,” and two “Teacher
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 12
Control Number 33-CC-20210928163425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SAN MARINO COMMUNITY CHURCH
FACILITY NUMBER: 191501069
VISIT DATE: 12/17/2021
NARRATIVE
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Agreements” were obtained.

- Pertaining to the allegation that “Unfingerprinted staff are supervising children”:

According to the Reporting Party (RP), there were two new staff in room 2 and RP does not believe that they have been fingerprint cleared because the Center normally does a "Meet the Teacher" event, but did not with these staff members.

On 10/01/21, LPA obtained the names of all staff who work at the Center. All staff present or not present were verified to have Criminal Background Clearance (what is referred to by RP as “fingerprint cleared.”)

According to form LIC 9163 “Request for Live Scan Service-Community Care Licensing,” Rawdaa Karass fingerprinted on 09/15/21; according to the “DOJ applicant fingerprint response,” she cleared on 09/18, and according to the “Teacher Agreement,” she began on 09/27. However, as of 10/01/21, she was not yet associated to the license

As she was verified to have Criminal Background Clearance but to not be associated to the license, the allegation that “Unfingerprinted staff are supervising children” has been determined to be Substantiated since Director Massoud would not have known that Rawdaa Karass has Department of Justice and Federal Bureau of Investigations clearance since Rawdaa Karass was not associated to the license.

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
Page: 9 of 12
Control Number 33-CC-20210928163425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SAN MARINO COMMUNITY CHURCH
FACILITY NUMBER: 191501069
VISIT DATE: 12/17/2021
NARRATIVE
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Based upon the evidence as presented above, the allegation has been determined to be Substantiated. A finding of Substantiated means that the preponderance of evidence standard has been met. California Code of Regulations, Title 22, Division 12, Chapter 1, Article 3, Section 101170 “Criminal Record Clearance" is being cited on the attached LIC 9099D.

Please refer to 9099D for documentation of deficiencies.


An exit interview has been conducted with, and a copy of this report has been signed by and provided to Director Jihan Massoud. Appeal Rights were provided and explained to same.

The Notice of Site Visit was posted by Director Jihan Massoud in LPA's presence. The Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required will result in the issuance of a citation and the assessment of a $100 civil penalty.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 12
Control Number 33-CC-20210928163425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SAN MARINO COMMUNITY CHURCH
FACILITY NUMBER: 191501069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2021
Section Cited
CCR
101170(e)(3)
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CRIMINAL RECORD CLEARANCE
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:
Request and be approved for a transfer of a criminal record exemption, as specified in Section 101170.1(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.
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On 10/01/21 Director Massoud provided LPA Bell with the CDL, LIC 508 and LIC 9163 to have Rawdaa Karass associatedto the license.
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-This requirement is not met as evidenced by: Rawdaa Karass started on 09/27/21. Though she has Criminal Background Clearance, ashe was not associated to the license until 10/01/21. A civil penalty of $500 has been assessed. *This poses a potential risk to the health and safety of children in care.*
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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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Betty BellTELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
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