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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493534
Report Date: 11/09/2020
Date Signed: 11/09/2020 06:01:50 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:TAVKHELIDZE FAMILY CHILD CAREFACILITY NUMBER:
197493534
ADMINISTRATOR:TAVKHELIDZE, AMRINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 660-3200
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:14CENSUS: DATE:
11/09/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Licensee - Amrin TavkhelidzeTIME COMPLETED:
12:59 PM
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On 11/09/2020 at 12:39pm Ericka Hill, Licensing Program Analyst (LPA) called the Licensee to conduct a Case Management visit to investigate an Unusual Incident Report received to the Regional Office on 10/28/2020.

LPA Hill interviewed the Licensee and other pertinent individuals.

At this time the investigation needs further investigation prior to concluding the findings.

An exit interview was conducted and a copy of this report and Notice of Site Visit was emailed to the licensee. LPA Hill requested the Licensee to sign and email the report back to the LPA.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Ericka HillTELEPHONE: (424) 301-3029
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
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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