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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197411145
Report Date: 09/23/2022
Date Signed: 09/23/2022 02:03:08 PM


Document Has Been Signed on 09/23/2022 02:03 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:DVORSKAYA ALTERNATIVE SCHOOLFACILITY NUMBER:
197411145
ADMINISTRATOR:MUKHURADZE, JINAFACILITY TYPE:
850
ADDRESS:1317 N. CRESENT HEIGHTS BLVD.TELEPHONE:
3238227999
CITY:WEST HOLLYWOODSTATE: CAZIP CODE:
90046
CAPACITY:41CENSUS: 6DATE:
09/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Viktoria Kovalenko, Teacher Person of Designated of Facility ResponsabilityTIME COMPLETED:
02:10 PM
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On 09/23/2022,11:01AM Licensing Program Analysts (LPA) Denise Miranda conducted an unannounced case management inspection to the facility to follow up on an incident that was self-reported by the facility and occurred on 08/08/2022. LPA observed 06 children being supervised by 2 staff. LPA met with Viktoria Kovalenko, Teacher, Designated Person of Responsibility and informed the purpose of the visit.

According to the incident report received on 08/17/2022, Child #1 alleged that on August 08th, 2022 was slapped on his arm by Staff#1.

LPA obtained a copy of LIC500 Personnel Record, LIC9040 Child Care Facility Roster. LPA conducted interviews with the staff and children in care. The child involved in the accident is no longer attending this school.

At this time, further investigation is needed.

The content of this report was read and discussed in detail at the time of the inspection with Teacher, Viktoria Kovalenko, Designated Person of Responsibility.

A copy of this report, Notice of Site Visit, were provided to Viktoria Kovalenko, Teacher Person of Designated of Facility Responsibility.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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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