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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198010536
Report Date: 04/29/2020
Date Signed: 04/29/2020 03:10:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:TILLMAN FAMILY CHILD CAREFACILITY NUMBER:
198010536
ADMINISTRATOR:TILLMAN, TRACEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 209-8686
CITY:LOS ANGELESSTATE: CAZIP CODE:
90061
CAPACITY:14CENSUS: DATE:
04/29/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Licensee, Tracy TillmanTIME COMPLETED:
04:00 PM
NARRATIVE
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This was a Case Management- Deficiencies conducted by T. Tran, Licensing Program Analyst (LPA) due to COVID-19 and precautionary measures. While conducting an investigation for a complaint, LPA observed licensee failed to report an incident that occurred on 02/25/2020 to the department of licensing which poses a potential health and safety risks to children in care.


Facility was cited a type B deficiency. See Facility Evaluation Report LIC 809D for deficiency cited.

An exit interview was conducted with the licensee. This report along with a notice of site visit, a copy of the appeal rights was via emailed to licensee. Via email with a read receipt or confirmation of receipt of email, which will act as the licensee's signature.

SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2020
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: TILLMAN FAMILY CHILD CARE
FACILITY NUMBER: 198010536
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2020
Section Cited

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Reporting Requirements
This requirement is not met as evidenced by based on record review facility failed to report an incident that occurred on 02/25/2020 which poses a potential health and safety risk to 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: Trevino CochranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR NAME: Tiffanie TranTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2020
LIC809 (FAS) - (06/04)
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