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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001772
Report Date: 09/26/2019
Date Signed: 09/26/2019 10:35:07 AM

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:CARILLON PRESCHOOLFACILITY NUMBER:
414001772
ADMINISTRATOR:HELENE, ENIDFACILITY TYPE:
850
ADDRESS:815 PORTOLA ROADTELEPHONE:
(650) 529-1335
CITY:PORTOLA VALLEYSTATE: CAZIP CODE:
94028
CAPACITY:29CENSUS: 27DATE:
09/26/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Enid HeleneTIME COMPLETED:
10:30 AM
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Licensing Program Analysts (LPAs) Kaur and Singh met with director, Enid Helene, for an inspection of plan of correction. Purpose of the inspection was explained.

During previous inspection, the facility received the citation for not having record of immunization of staff members. During today's inspection, LPAs reviewed the facility records. LPAs observed the facility has record of staff's required immunization. LPAs observed facility has record of children's immunization on file. Per director, facility staff has completed the mandated reporter training. Director agreed to submit the completion certificates to the department.

No deficiencies are cited today. Copy of this report is reviewed and provided to the director. Notice of site visit is posted and shall remain posted for next 30 days.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Harsimran KaurTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2019
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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