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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198010536
Report Date: 04/29/2020
Date Signed: 07/21/2020 03:02:28 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2020 and conducted by Evaluator Tiffanie Tran
PUBLIC
COMPLAINT CONTROL NUMBER: 54-CC-20200309165023
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
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Licensee, Tracy TillmanTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Personal Rights- Daycare child sustained a fracture left elbow while in care.
INVESTIGATION FINDINGS:
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This was a complaint investigation conducted by T. Tran, Licensing Program Analyst (LPA) due to COVID-19 and precautionary measures. This final finding complaint was delivered with Licensee, Tracy Tillman by use of via telephone.

The investigation included records reviewed and interviews conducted. On 02/25/2020, C1 was hit by the swing and hit the head on the concrete area and sustained a fracture on a left elbow, a full cast was required. However, based on the interviews conducted, this incident appears to be an isolated accident, not a result of personal rights violation. Therefore, this allegation has been determined unsubstantiated. Unsubstantiated – A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

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.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 54-CC-20200309165023
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
CCR
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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
LIC9099 (FAS) - (06/04)
Page: 2 of 2