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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493875
Report Date: 11/02/2021
Date Signed: 11/02/2021 12:14:47 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:FULLER FAMILY CHILD CAREFACILITY NUMBER:
197493875
ADMINISTRATOR:FULLER, MARLOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 505-9749
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY:14CENSUS: 11DATE:
11/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Marlo Fuller, LicenseeTIME COMPLETED:
12:25 PM
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On 11/02/2021 Licensing Program Analyst (LPA) Shandra Powell conducted an Case Management visit to capture signatures and to print complete Required 1 Year Report, Deficiency Page, Civil Penalty, and Appeal Rights. During the Required Annual Inspection on 10/28/2021 LPA experienced a consistency check and was unable to capture signatures and print original report.

During Required Annual Inspection LPA provided licensee with a hand written report and a hand written notice of site visit.
SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) -30-3038
LICENSING EVALUATOR NAME: Shandra PowellTELEPHONE: (424) 301-3053
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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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