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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206861
Report Date: 11/10/2021
Date Signed: 11/10/2021 02:27:03 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/02/2021 and conducted by Evaluator Les Xiong
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20211102140050
FACILITY NAME:BELMAR VILLAFACILITY NUMBER:
107206861
ADMINISTRATOR:HRIPSIME MAKARYANFACILITY TYPE:
740
ADDRESS:2020 NORTH WEBER AVENUETELEPHONE:
(559) 486-5977
CITY:FRESNOSTATE: CAZIP CODE:
93705
CAPACITY:100CENSUS: DATE:
11/10/2021
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Hripsime (Kristina) MakaryanTIME COMPLETED:
02:13 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Violation of General Food Service Requirements
Violation of Personal Rights
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) L. Xiong conducted the complaint investigation visit to the facility.
During the course of this investigation LPA reviewed facility files and interviewed staff and residents relevant to the complaint investigation. It was determined that the above allegations: Violation of General Food Service Requirements and Violation of Personal Rights are UNFOUNDED. During the tour of the facility, the dining halls were open for dining and R1 was asked to dine in his room due to his continual disruptive behavior in the dining hall. R1's disruptive behavior have also caused altercations with other residents, one resulting in R2 hitting R1. This agency has investigated the complaint alleging (Violation of General Food Service Requirements and Violation of Personal Rights). We have found that the complaint was unfounded, therefore we have dismissed the complaint.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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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