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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197411145
Report Date: 10/07/2022
Date Signed: 10/07/2022 03:45:55 PM


Document Has Been Signed on 10/07/2022 03:45 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:
(323) 822-7999
CITY:WEST HOLLYWOODSTATE: CAZIP CODE:
90046
CAPACITY:41CENSUS: 7DATE:
10/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Jina Mukhuradze, Licensee TIME COMPLETED:
03:45 PM
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On 10/07/2022, 3:01PM, Licensing Program Analyst (LPA) Denise Miranda conducted an unannounced case management inspection to the facility to deliver the final investigation of the incident that was self-reported by the facility and occurred on 08/08/2022. LPA observed 7 children being supervised by 2 staff and Director. LPA met with Jina Mukhuradze, Director 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, they were slapped on the arm by Staff #1.

During the investigation, LPA interviewed the Director, staff, and attempted to interview children in care. LPA attempted to contact Child #1’s parents for an interview with both parents and Child #1 but to not avail. LPA obtained a copy of the children's roster and copies of supporting documentation which included a police report. The police report dated 8/21/2022, notes the incident as a suspicious circumstance and concluded their investigation.

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.
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 to Jina Mukhuradze, Director, including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
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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