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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206861
Report Date: 07/10/2024
Date Signed: 07/10/2024 10:15:50 AM

Substantiated


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
05/02/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20240502170130
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: 65DATE:
07/10/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Adminsitrator Makaryan Hripsime,TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility staff did not ensure restroom is clean and sanitized.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced facility visit to open a complaint on the allegations listed above. Administrator responded to the facility to assist with the visit. LPA met with Facility Adminsitrator, Makaryan Hripsime, and explained the purpose of today's visit.

LPA toured the facility. LPA interviewed staff. LPA checked several bathrooms and two community bathrooms. LPA observed orangish pink and black mold in community shower. LPA took photos. LPA observed the in room bathrooms to be clean.

Based on observation and interviews, Facility staff did not ensure restroom is clean and sanitized.
Based on observation and interviews, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D.

A copy of this report along with appeal rights and plan of correction were provided.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
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 3
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
05/02/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20240502170130

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: 65DATE:
07/10/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Adminsitrator Makaryan Hripsime,TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility staff do not ensure residents are served food of good quality.
Facility staff do not provide adequate food service to residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced facility visit to open a complaint on the allegations listed above. LPA met with Facility Adminsitrator, Makaryan Hripsime, and explained the purpose of today's visit.

LPA toured the kitchen and checked the food supply. LPA observed residents in the dining area eating a banana and an english muffin with cheese and eggs. LPA observed other options of cereal. LPA asked kitchen staff what was for lunch. Kitchen staff stated meatballs, mashed potatoes with gravy and salad. LPA reviewed the menu. LPA took photos of food supply and observed an adequate food supply.

Based on observation and interviews, it is undetermined whether or not the allegation occurred. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
A copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20240502170130
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BELMAR VILLA
FACILITY NUMBER: 107206861
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2024
Section Cited
CCR
87303(a)(1)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee agrees to clean both community showers and submit photos by POC due date 7/12/24.
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 (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by Licensee did not keep community showers free from mold, which poses a potential health safety and or personal rights risk to residents 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: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3