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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004214
Report Date: 08/28/2019
Date Signed: 08/28/2019 04:17:03 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:CHAMPIONS-HOOVER ELEMENTARYFACILITY NUMBER:
414004214
ADMINISTRATOR:PAYNE-ALEX, TAMARAFACILITY TYPE:
840
ADDRESS:2220 SUMMIT DRIVETELEPHONE:
(408) 348-1610
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:56CENSUS: 0DATE:
08/28/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Leila RashidTIME COMPLETED:
04:30 PM
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Licensing Program Analyst, LPA Yee conducted a case management inspection today. This is a school-age program. LPA measured and inspected the school-age play yard today. No apparent hazards were observed during the inspection. The license will be approved for 56 children effective today. LPA hand-delivered the new license today.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2019
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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