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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191870577
Report Date: 09/08/2023
Date Signed: 09/08/2023 10:12:14 AM


Document Has Been Signed on 09/08/2023 10:12 AM - It Cannot Be Edited

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:WILLOWBROOK CHILD DEVELOPMENT CENTERFACILITY NUMBER:
191870577
ADMINISTRATOR:SONIA LOVEFACILITY TYPE:
850
ADDRESS:12829 SO. JARVIS AVE.TELEPHONE:
(310) 352-4486
CITY:LOS ANGELESSTATE: CAZIP CODE:
90061
CAPACITY:73CENSUS: 40DATE:
09/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Shawna MizellTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) and Warren Birks conducted a Case Management Incident inspection. This inspection is regarding a personal rights incident took place on June 16, 2023. LPA met with Education Curriculum Specialist Shawna Mizell who provided information and assistance during the inspection.

During the course of two case management inspections, LPAs conducted interviews with six children and three staff. LPAs also reviewed the following documents: a June 20, 2023 unusual incident report, employee HR reports, and employee written declaration statements. During interviews conducted, LPAs received no corroborated disclosures indicating that a personal rights incident occurred.

Staff reported the incident on 6/22/2023 via telephone call and emailed written report. The Information provided matches the incident report. There are no deficiencies cited during this inspection.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview was conducted with Education Curriculum Specialist Shawna Mizell.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren BirksTELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
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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