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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493534
Report Date: 12/11/2020
Date Signed: 12/11/2020 12:17:58 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: 10DATE:
12/11/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Amrin TavkhelidzeTIME COMPLETED:
12:30 PM
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On 12/11/2020 at 12:00pm Licensing Program Analyst (LPA) Ericka Hill called the Licensee to follow-up and deliver the findings to an Unusual Incident Report received from the Licensee on 11/03/2020.

On 10/27/2020 an Unusual Incident was reported to Community Care Licensing (CCL) regarding two children, C1 and C2. During the investigation, the Licensee, S1, P1, and P2 stated that C1 and C2 engaged in inappropriate touching while in care. Interviews also revealed that S1 was assisting two school-age children with school work, when the incident occurred.

Based on the interviews conducted and records reviewed, although the Licensee and S1 did follow reporting requirements and in compliance with capacity regulations, two children engaged in inappropriate touching while in care at the facility. Therefore, the findings are found to be Substantiated, meaning that the allegation is valid because the preponderance of evidence standard has been met.

Type A deficiency was cited. See LIC 809-D for details.
Each report (documenting a Type A citation)shall remain posted for 30 days along with the Notice of Site Visit. **In addition; A copy of this report must be provided to the authorized representatives of all currently enrolled children and any newly enrolled child for the following 12 months.

The ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) shall be signed and kept in each of the children’s records. The report shall be provided no later than the next business day or the next day the child is in care.

An exit interview was conducted and a copy of the LIC809, LIC809D, and Notice of Site Visit was given to the Licensee. LPA Hill requested the Licensee to read, sign, and email the LIC809 and LIC809D back to LPA Hill.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Ericka HillTELEPHONE: (424) 301-3029
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 197493534
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2020
Section Cited

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102423(a)(2) Each child receiving services from a family child care home shall have certain rights that...include, but are not limited to, the following...
To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement was not met as evidence by:
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Based on interviews conducted and records reviewed facility staff did not ensure a safe environment, resulting in C1 and C2 inappropriately touching one another. This poses an immediate Health and Safety risk to the children 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.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Ericka HillTELEPHONE: (424) 301-3029
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2020
LIC809 (FAS) - (06/04)
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