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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434415451
Report Date: 09/12/2024
Date Signed: 09/12/2024 01:08:58 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2024 and conducted by Evaluator Samantha Yip
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20240909210908
FACILITY NAME:AMBARTSUMOVA, KARINAFACILITY NUMBER:
434415451
ADMINISTRATOR:KARINA AMBARTSUMOVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 306-7090
CITY:SAN JOSESTATE: ZIP CODE:
95129
CAPACITY:14CENSUS: 12DATE:
09/12/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Karina AmbartsumovaTIME COMPLETED:
10:53 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Smoking is permitted on the premiser
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced complaint investigation. LPA met with Licensee Karina Ambartsumova and explained the reason for the inspection. Licensee called her daughter who helped translate.

During today's inspection, LPA inspected the physical plant. LPA also interviewed Licensee, her assistant, and volunteer. Based on the information obtained, the above allegation is found to be UNSUBSTANTIATED, meaning although, the above allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted and report was reviewed with Licensee Karina Ambartsumova. A notice of site visit has been issued and must remain posted for 30 days.
Focus Lanaguage International was used to translate report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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