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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013414625
Report Date: 12/10/2021
Date Signed: 12/10/2021 02:08:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:ADVENTURE TIME - VALLEJO MILLFACILITY NUMBER:
013414625
ADMINISTRATOR:HADFIELD, ELAINEFACILITY TYPE:
840
ADDRESS:38569 CANYON HEIGHTS DRIVETELEPHONE:
(510) 742-6440
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:75CENSUS: 2DATE:
12/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jayjay NagayoTIME COMPLETED:
02:15 PM
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LPA arrived to issue an amended Facility Report due to an appeal of finding. Center Director was not available due to a family emergency, therefore Jayjay Nagayo was called and came to sign the amended report.

There were two teachers, a special Ed teacher and two children present.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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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