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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418922
Report Date: 05/08/2019
Date Signed: 05/08/2019 03:48:27 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:PHAM FAMILY CHILD CAREFACILITY NUMBER:
197418922
ADMINISTRATOR:PHAM, TINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(424) 675-4403
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:14CENSUS: 11DATE:
05/08/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Tina Pham - LicenseeTIME COMPLETED:
04:00 PM
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On 5/8/19, Licensing Program Analyst (LPA) Helen Estrella conducted a Case Management incident visit to the conclude a Unusual/Injury Report that occurred at the family child care home on 2/12/19. Upon arrival, LPA met with the licensee and was informed of the visit. The El Segundo Regional Office received the Unusual Incident report on 2/20/19 by the licensee Tina Pham.

Based on the facts gathered and interviews conducted, the facility was in compliance during the incident on 2/12/19. At the time of the incident and based on available facts, it does not appear this incident was the result of a Title 22 and/or Health & Safety Code violation. Although the child sustained an elbow injury, the licensee responded immediately to the child's needs and assisted the child to prevent further self-harm. Parents were notified immediately.

The contect of this report was read and discussed in detail with the licensee. The facility appears in compliance per Title 22 regulations. Type A and B deficiencies will not be cited today 5/8/19.

An exit interview was conducted, a copy of this report and notice of site visit provided to the licensee.
SUPERVISOR'S NAME: Jennie FerreiraTELEPHONE: (424) 301-3073
LICENSING EVALUATOR NAME: Helen EstrellaTELEPHONE: (424) 301-3073
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
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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