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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414000455
Report Date: 09/11/2019
Date Signed: 09/11/2019 03:39:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CITY OF SAN MATEO REC. DEPT - BERESFORD KIDS CLUBFACILITY NUMBER:
414000455
ADMINISTRATOR:CAROLYN SHAVELFACILITY TYPE:
840
ADDRESS:2720 ALAMEDA DE LAS PULGASTELEPHONE:
(650) 522-7440
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:42CENSUS: 36DATE:
09/11/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jessica LiraTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Marie Rodriguez made a Case Management visit in conjunction with Annual Required inspection. LPA met with Site Director Jessica Lira who wanted to discuss the change of Director on license from Carolyn Shavel to Tracy Stuhr Brumett. LPA provided Site Director with a checklist of what is needed to change Director on license. LPA requested for documents listed on checklist to be sent to CCLD office by September 30, 2019 and to contact LPA if more time is needed to provide them.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) -26-8800
LICENSING EVALUATOR NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2019
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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