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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624204
Report Date: 01/29/2024
Date Signed: 01/29/2024 12:51:45 PM

Document Has Been Signed on 01/29/2024 12:51 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SIMONYAN, MARIYAFACILITY NUMBER:
343624204
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
01/29/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Mariya SimonyanTIME COMPLETED:
01:15 PM
NARRATIVE
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On January 29, 2024 Licensing Program Analysts Stephanie Piring and Soleil Marx met with licensee Mariya Simonyan for the purpose of an unannounced licensee initiated case management inspection. The purpose of today's inspection is for a capacity increase from a small licensee to a large license. Fire clearance was granted on 01/18/2024 by Sacramento Metro Fire Department.

During the inspection there was a census of six children in care being supervised by the licensee. All individuals subject to criminal background review have obtained a criminal record clearance. Facilities hours of operation are Monday through Friday 07:00 AM to 05:30 PM.

A health and safety inspection was conducted in the areas accessible to children. The off-limits areas include: the entire main house. Licensee understands that children may never enter off-limit areas.

LPAs observed an accessible body of water, an above ground fountain, on the premises in front of the main house. The fountain is approximately 35 feet long, 20 feet wide, and 1.5 feet deep, which was filled and actively running which poses an immediate risk to children in care. Licensee understood at the time of pre-licensing that the fountain was to remain drained at all times. Licensee immediately drained the fountain at the time of the visit. LPAs observed a creek on the premises with a wrought iron fence separating that portion of the property. Licensee acknowledges 100% supervision is required near bodies of water. Licensee stated there are no weapons on the premises.

LPA observed a children's roster and fire drill log, the last fire drill was conducted September 2023. LPAs observed a sample of children’s files, all which contained the required documentation.

Based on Today’s inspection, Title 22 Deficiencies are being cited on 809-D and an immediate civil penalty of $500 is being assessed.



SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Stephanie Piring
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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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Document Has Been Signed on 01/29/2024 12:51 PM - It Cannot Be Edited


Created By: Stephanie Piring On 01/29/2024 at 12:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIMONYAN, MARIYA
FACILITY NUMBER: 343624204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2024
Section Cited
CCR
102417(g)(5)

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All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence. This requirement is not met as evidenced by:
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Licensee immediately drained fountain and stated they would keep it drained and plug up the water spout used to fill. LPA Piring will do a return visit to clear the deficiency.
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Based on observation, the licensee did not ensure bodies of water were inaccesible to chidlren in care 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.
SUPERVISOR'S NAME:Natalie Dunaway
LICENSING EVALUATOR NAME:Stephanie Piring
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SIMONYAN, MARIYA
FACILITY NUMBER: 343624204
VISIT DATE: 01/29/2024
NARRATIVE
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The Licensee was informed that this report dated 01/29/2024 documents one Type A citation which shall be posted for 30 consecutive days. The Licensee shall also provide a copy of this licensing report to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. Licensee has been provided with appeal rights.

Licensees request to increase capacity is pending further manager review.

Exit interview conducted and report was reviewed with the licensee, Mariya Simonyan. Notice of site provided and must remain posted for 30 days.

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Stephanie Piring
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC809 (FAS) - (06/04)
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