<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198009841
Report Date: 04/30/2020
Date Signed: 04/30/2020 11:53:29 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
04/16/2020 and conducted by Evaluator Judy Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20200416141917
FACILITY NAME:ALSOUROUGI FAMILY CHILD CAREFACILITY NUMBER:
198009841
ADMINISTRATOR:ALSOUROUGI, JOSEFINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(213) 413-2209
CITY:LOS ANGELESSTATE: CAZIP CODE:
90026
CAPACITY:14CENSUS: 2DATE:
04/30/2020
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Josefina Alsourougi TIME COMPLETED:
11:50 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Reporting requirements.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Judy Mora contacted the facility via telephone to initiate a subsequent complaint investigation inspection due to COVID-19 and pre-cautionary measures. LPA Mora identified herself and spoke to Licensee. LPA discussed the purpose of the call. Call was then transferred to a tele-visit via Zoom. Call was then transferred to a tele-visit via Zoom. Licensee's assistant, Elvira Javier, was also present.

During the course of the investigation LPA conducted interviews and reviewed records. An unusual incident occurred at the facility on or around April 8th, 2020. The Licensee did not report this incident to the Department as required. Based on the available information, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations,(Title 22, Division 12 & Chapter Number 6), are being cited on the attached LIC. 9099D. This posed a potential Health & Safety risk to clients in care.

*REPORT CONTINUES ON NEXT PAGE
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 981-3371
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2020
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 5
Control Number 33-CC-20200416141917
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: ALSOUROUGI FAMILY CHILD CARE
FACILITY NUMBER: 198009841
VISIT DATE: 04/30/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Upon receipt of this report, the licensee shall post ANY licensing report documenting a type “A” citation or substantiated complaint. This must remain posted for 30 days during hours of operation. In addition to posting this report, the licensee will also provide copies to the parents of the children in care for up to one year.

A copy of the LIC 9224 - Acknowledgement of Receipt of Licensing Reports was provided.

An exit phone interview has been conducted with Licensee Alsourougi. Appeal Rights were verbally explained to the Licensee as well. A copy of this report has been signed by LPA Mora.

This report along with the form LIC 9224 and Appeal Rights will be scanned via e-mail to the Licensee, who understands that an electronic “Read Receipt” and/or confirmation of receipt of the e-mail confirms receipt of the report and constitutes an electronic signature. A hard copy of this report, form LIC 9224 and the Appeal Rights will be placed in the mail and the Licensee agrees to sign the bottom of each page of the 9099 and return the originals to LPA Mora in-person or via U.S. Mail.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 981-3371
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/16/2020 and conducted by Evaluator Judy Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20200416141917

FACILITY NAME:ALSOUROUGI FAMILY CHILD CAREFACILITY NUMBER:
198009841
ADMINISTRATOR:ALSOUROUGI, JOSEFINAFACILITY TYPE:
810
ADDRESS:2326 W. BERKELEY AVENUETELEPHONE:
(213) 413-2209
CITY:LOS ANGELESSTATE: CAZIP CODE:
90026
CAPACITY:14CENSUS: DATE:
04/30/2020
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Josefina Alsourougi TIME COMPLETED:
11:50 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
A child sustained a bruise while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Judy Mora contacted the facility via telephone to initiate a subsequent complaint investigation inspection due to COVID-19 and pre-cautionary measures. LPA Mora identified herself and spoke to Licensee. LPA discussed the purpose of the call. Call was then transferred to a tele-visit via Zoom. Licensee's assistant, Elvira Javier, was also present.

During the course of the investigation LPA conducted interviews and reviewed records. 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, therefore the allegation is unsubstantiated.

An exit phone interview has been conducted with Licensee Alsourougi. Appeal Rights were verbally explained to the Licensee as well. A copy of this report has been signed by LPA Mora.

*REPORT CONTINUES ON NEX PAGE
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 981-3371
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 33-CC-20200416141917
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: ALSOUROUGI FAMILY CHILD CARE
FACILITY NUMBER: 198009841
VISIT DATE: 04/30/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This report along with the form LIC 9224 and Appeal Rights will be scanned via e-mail to the Licensee, who understands that an electronic “Read Receipt” and/or confirmation of receipt of the e-mail confirms receipt of the report and constitutes an electronic signature. A hard copy of this report, form LIC 9224 and the Appeal Rights will be placed in the mail and the Licensee agrees to sign the bottom of each page of the 9099 and return the originals to LPA Mora in-person or via U.S. Mail.


*END OF REPORT
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 981-3371
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 33-CC-20200416141917
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: ALSOUROUGI FAMILY CHILD CARE
FACILITY NUMBER: 198009841
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/08/2020
Section Cited
CCR
102416.2(b)
1
2
3
4
5
6
7
Reporting Requirements.
The licensee shall report to the Department any of the events as specified in Health and Safety Code Section 1597.467(b)(1)(A)
through (b)(1)(C) that occur during the operation of the family child care home.
This requirement was not met as evidenced by
1
2
3
4
5
6
7
The licensee will submit the LIC 624 to the Department with the incident which occurred. Licensee states she will report all unusual incidents to the Department. LPA provided the LIC 624 via email.
8
9
10
11
12
13
14
the interviews conducted. The incident that occurred on or around 04/08/2020 was not reported to the Department. The facility was aware of the incident on the day it occurred, and the incident was not reported within the required 24 hours. This was a potential risk to the health and safety of children in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Judy MoraTELEPHONE: (323) 981-3371
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5