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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197407376
Report Date: 05/04/2022
Date Signed: 05/04/2022 01:22:20 PM

Document Has Been Signed on 05/04/2022 01:22 PM - 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:TSINMAN FAMILY CHILD CAREFACILITY NUMBER:
197407376
ADMINISTRATOR:TSINMAN, GRIGORIY & RITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 851-5935
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
05/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee, Rita Tsinman TIME COMPLETED:
02:00 PM
NARRATIVE
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During case management visit it was determined that licensee did not report incident that occurred on 2/2/2022 to licensing as required. LPA confirmed with licensee that incident was not reported. In accordance with California Code of Child Care Title 22 regulation this facility is cited (1) deficiency; this is a violation of Title 22 Care Regulation-102416.2 Reporting Requirements (b) The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.457(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child home. This is a Type B violation which poses a potential Health, Safety or Personal Risk to children in care. Refer to Licensing Report LIC 9099 D.

LPA discussed the importance of reporting unusual incidents. LPA advised to report unusual
incidents reports to the Department by telephone, email or fax within the Department's next
business day during normal working hours 8am- 5pm. LPA reviewed LIC 624 and provided licensee with a copy. As Proof of Correction (POC) licensee agreed to submit declaration (LIC 855) of incident reporting. Copy of declaration will be submitted to LPA by May 16, 2022.

Please Note: This report is a recreation of case management visit conducted on 4/28/2022. Original report lost on Community Care Licensing database. Correction date from 2/22/22 on original report to correct date of 2/2/22.

Exit interview conducted and this report reviewed with licensee. Copy of Appeal Rights given.
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Dalicia Adkins
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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Document Has Been Signed on 05/04/2022 01:22 PM - It Cannot Be Edited


Created By: Dalicia Adkins On 05/04/2022 at 12:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: TSINMAN FAMILY CHILD CARE
FACILITY NUMBER: 197407376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/04/2022
Section Cited
CCR
102416.2(b)

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102416.2 (b) Reporting Requirements. The licensee shall report to the Department any of
the events as specified in Health and Safety Code Section 1597.467(b)(1)(A) through (b)(1)(C) that occur. during the operation of the family child care home.This requirement is not
met as evidenced by:
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Licensee will submit LIC 855 declaration to LPA for the citation informing the department that reporting requirements will be adhered to, incidents will be reported verbally and a written
LIC 624 will be submitted by 7 business days.Licensee agree to submit Declaration to LPA by May 16,2022.
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Licensee did not report the incident. LPA confirmed with licensee that she did not submit LIC 624 to the department.
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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:Karren Starks
LICENSING EVALUATOR NAME:Dalicia Adkins
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022


LIC809 (FAS) - (06/04)
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