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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198010536
Report Date: 09/13/2024
Date Signed: 09/13/2024 03:10:40 PM

Document Has Been Signed on 09/13/2024 03:10 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:TILLMAN FAMILY CHILD CAREFACILITY NUMBER:
198010536
ADMINISTRATOR/
DIRECTOR:		TILLMAN, TRACEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 209-8686
CITY:LOS ANGELESSTATE: CAZIP CODE:
90061
CAPACITY: 14TOTAL ENROLLED CHILDREN: 24CENSUS: 3DATE:
09/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Adriane Carrington, Licensee AssistantTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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 (LPA) Ashley Calderon arrived to the facility and met with Staff Adriane Carrington. Ms. Carrington gave LPA permission for a self guided tour including "off limit" areas. The purpose of the inspection was to conduct a complaint inspection. Due to LPAs observations and staff interviews, LPA conducted a Case Management inspection.

LPA reviewed Staff present on todays visit record and Infant Record (Child #1). Staff was present with 3 children including 1 infant. LPA consulted via telephonically with Licensee Tracy Tillman regarding records for staff and records for children . LPA provided LIC Entrance Checklist for Family Child Care home and informed Licensee to review LIC311D Records Form. LPA advised to review PIN 20-24-CCP on infant safe sleep.

The following was observed and per interviews:
  • Child #1 (infant)- did not have a 15 minute Sleep Log record. LPA provided a 15 min sleep log and reviewed safe sleep regulation with staff Ms. Carrington.
  • Staff present during visit, record was reviewed, Staff missing Immunization Records.
  • During interview with Ms.Tillman stated Staff #1 informed LPA Calderon that all other staff working at the facility are in the process of getting immunization records.


The following deficiencies listed on the attached LIC 809-D (deficiency page) are being cited in accordance with California Code of Regulations Title 22,Section CCR & H&S.

An exit interview was conducted with Staff Adriane Carrington. Appeal Rights and Notice of Site visit was given.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2024
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 2
Document Has Been Signed on 09/13/2024 03:10 PM - It Cannot Be Edited


Created By: Ashley Calderon On 09/13/2024 at 02:31 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
, 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: 09/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2024
Section Cited
HSC
1597.622(a)(1)

1
2
3
4
5
6
7
(a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a FCC...if he or she has not been immunized against influenza, pertussis, and measles...

This requirement was not met as evidence by:
1
2
3
4
5
6
7
Licensee will get all staff who assist have immunization records in files per staff. LPA provided list of records needed and LIC126 FCC checklist Info for personnel records guidance. Provide immunization records to LPA by poc due date.
8
9
10
11
12
13
14
Staff #1 did not have proper immunization's present at the facility, records against Tuberculosis, influenza, pertussis, and measles was not observed or reviewed. Per Staff #1, needs to find immunization records.
8
9
10
11
12
13
14
Type B
10/14/2024
Section Cited
CCR102425

1
2
3
4
5
6
7
Infant Safe Sleep
(j) The provider shall supervise infants while they are sleeping and adhere to the following requirements: (1) The provider shall physically check on the infant every 15 minutes.
1
2
3
4
5
6
7
LPA provided Staff Ms.Carrington 15 min Sleep log and explained how to use log and how to check infant during sleep. LPA provided Safe Sleep Regulation consulation. PIN 20-24-CCP info and Regulation for Safe Sleep was provided to review. Licensee will provide sleep log for Child #1 by poc date.
8
9
10
11
12
13
14

This requirement was not met as evidence by:

Staff #1 stated infant does not have a 15 min sleep log and only physically checks on infants.
8
9
10
11
12
13
14
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:Valarie Cook
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2