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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197411153
Report Date: 08/19/2021
Date Signed: 08/19/2021 03:20:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:JOHNSON FAMILY CHILD CAREFACILITY NUMBER:
197411153
ADMINISTRATOR:JOHNSON, LA TRICIA D.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 753-4453
CITY:LOS ANGELESSTATE: CAZIP CODE:
90043
CAPACITY:14CENSUS: 0DATE:
08/19/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:42 PM
MET WITH:Latricia JohnsonTIME COMPLETED:
03:37 PM
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On 08/19/2021 at 2:42pm LPA conducted a follow up Case Management Visit regarding deficiencies observed on 08/11/2021. Due to technical issues LPA was unable to provide licensee with a copy of the Facility Evaluation Report (LIC 809, 809C and 809D. LPA conducted a unannounced case follow up visit andprovided licensee with Facility Evaluation Report 809, 809C and 809D. LPA provided licensee with all blank Children Record Documents and a blank roster. Licensee was instructed to submit documentation to office by 08/23/2021 by Close of Business see 809D.
SUPERVISOR'S NAME: Peter FloresTELEPHONE: (424) 301-3077
LICENSING EVALUATOR NAME: Laticia S ThompsonTELEPHONE: (424) 301-3048
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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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