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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343624118
Report Date: 12/07/2022
Date Signed: 12/07/2022 01:30:55 PM

Substantiated


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
11/14/2022 and conducted by Evaluator Amanda Sutter
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20221114105700
FACILITY NAME:MOVSISYAN, HASMIKFACILITY NUMBER:
343624118
ADMINISTRATOR:MOVSISYAN, HASMIKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 600-0080
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:14CENSUS: 0DATE:
12/07/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Hasmik MovsisyanTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Licensee does not live at facility
INVESTIGATION FINDINGS:
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On December 7, 2022 at 12:45 PM, Licensing Program Analysts (LPA) Amanda Sutter met with licensee Hasmik Movsisyan to open and close a complaint alleging that the licensee does not live at facility. There were no children present at the facility during today's inspection. Licensee has submitted a change of location application with the facility number 343624714. Based on the interviews, documents obtained, and observations made at the facility with Licensee and information received the allegation 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. Appeal rights and a notice of site visit were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
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 2
Control Number 03-CC-20221114105700
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: MOVSISYAN, HASMIK
FACILITY NUMBER: 343624118
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/08/2022
Section Cited
CCR
102352(H)(1)
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(h) (1) "Home" means the licensee's residence as defined by Government Code Section 244.
This requirement is not met as evidenced by:
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Licensee has submitted a change of location application with the facility number 343624714.
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Based on interviews and observations, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2