Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343617941
Report Date: 03/07/2016
Date Signed: 03/07/2016 10:33:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:SAMUSENKO, LYUBOVFACILITY NUMBER:
343617941
ADMINISTRATOR:SAMUSENKO, LYUBOVFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 727-3271
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:14CENSUS: 7DATE:
03/07/2016
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lyubov SamusenkoTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Steven Lunn made a POC visit to the facility and met with Licensee's assistant Nadia. Nadia stated the licensee went on a two day vacation and will be back on Wednesday. The reason for the visit was discussed to clear the deficiencies cited during an Annual Random Visit conducted on 3/1/2016.

LPA toured the facility during today's visit. LPA cleared deficiencies previously cited.

POC letter was provided. Exit Interview Conducted. No deficiencies cited today.
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Steven LunnTELEPHONE: 916-216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2016
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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