<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364843790
Report Date: 06/19/2019
Date Signed: 06/19/2019 09:16:21 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:BURRELL FAMILY CHILD CAREFACILITY NUMBER:
364843790
ADMINISTRATOR:BURRELL, TIERRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 362-3565
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY:14CENSUS: 7DATE:
06/19/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Tierra BurrellTIME COMPLETED:
09:31 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst's (LPAs) Thompson-Miller and Smith met with Licensee, Tierra Burrell, for a Case Management Other inspection. The purpose of the inspection is to verify Charaty Calderon is not employed or residing at the Family Child Care Home. Per Licensee, Ms. Calderon has been removed from any contact with child care children and will not be physically present at the child care home effective June 19, 2019. A copy of letter dated June 14, 2019, Order to Individual (Charaty Calderon) of Immediate Exclusion From All Facilities was provided to Licensee Tierra Burrell on this date.

A Family Child Care Home Addendum to Notification of Parents' Rights (Regarding Removal/Exclusion) Form LIC 995B has been provided to Licensee Tierra Burrell to give to parents to read and sign acknowledgement of receipt of Form LIC 995B.

Exit interview conducted and a copy of report was read and provided to Licensee, Tierra Burrell.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Linda Thompson-MillerTELEPHONE: (661) 568-8186
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1