343623676-8-10-2021-03-CC-RSAA-C5ZSVM-20210818141256

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 343623676
Report Date: 08/10/2021
Date Signed: 08/10/2021 01:29:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/21/2021 and conducted by Evaluator Tanya Washington

PUBLIC

COMPLAINT CONTROL NUMBER: 03-CC-20210421144005

FACILITY NAME:	SMYSHKOVA, ANNA		FACILITY NUMBER:	343623676
ADMINISTRATOR:	SMYSHKOVA, ANNA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 949-6332
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95841
CAPACITY:	14	CENSUS: 7	DATE:	08/10/2021
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Anna Smyshkova		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Lack of supervision

INVESTIGATION FINDINGS:

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On 08/10/2021 at 12:45 PM, LPA Washington met with Licensee, Anna Smyshkova to deliver complaint finding for the allegation above. During today's inspection LPA observed care and supervision of seven children supervised by the Licensee.

The investigation was conducted by Investigation Branch, Investigator Jorge Martinez. It was alleged that inappropriate touching occurred between minor children while they were present in the facility.
Investigator Martinez conducted interviews with children, parents, and Licensee. During the course of the investigation Investigator Martinez gathered that at least two minor children may have participated in some inappropriate touching which occurred briefly over clothes.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

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 3

Control Number 03-CC-20210421144005

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: SMYSHKOVA, ANNA	FACILITY NUMBER: 343623676
	VISIT DATE: 08/10/2021

NARRATIVE

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The Licensee was present in the home when this occurred, however she was putting younger children to sleep and did not observe the interaction. Due to Licensee not witnessing the incident and specific explanation of the incident by Child #1, Investigator Martinez substantiated the complaint of lack of supervision.

Based upon evidence obtained, there is a preponderance of evidence to support the allegation; therefore, the finding is SUBSTANTIATED.

Title 22 deficiency is cited on the subsequent page of this report (LIC9099D). Licensee acknowledges, that for TYPE A DEFICIENCIES ONLY upon receipt, Licensee shall post LIC9099-D with Type A deficiency for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the Licensee. This report was reviewed with the Licensee. Report, appeal rights, LIC9224, and notice of site visit was provided during today's inspection.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 03-CC-20210421144005

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: SMYSHKOVA, ANNA	FACILITY NUMBER: 343623676
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/10/2021 Section Cited CCR 102417(a)	1 2 3 4 5 6 7	The licensee shall be present in the home and shall ensure that children in care are supervised at all times. This requirement is not met as evidenced: Investigator Martinez gathered that at least two minor children may have participated in some inappropriate touching which occurred briefly over clothes.	1 2 3 4 5 6 7	Licensee stated that she will ensure that when she puts kids down for a nap the door will remain open so she can hear children in the other room.
	8 9 10 11 12 13 14	This is immidiate risk of 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: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3