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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004859
Report Date: 04/06/2022
Date Signed: 04/06/2022 04:56:21 PM


Document Has Been Signed on 04/06/2022 04:56 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:JIMENEZ, ANDREAFACILITY NUMBER:
414004859
ADMINISTRATOR:JIMENEZ, ANDREAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 454-7249
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:14CENSUS: 5DATE:
04/06/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Andrea JimenezTIME COMPLETED:
03:20 PM
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On April 6th, 2022 at approximately 2:35pm, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an Unannounced Case Management Visit and met with Licensee, Andrea Jimenez. Purpose of visit was explained. Licensee has requested to add backyard part of the day care areas. Present during the visit were licensee and an assistant caring for 5 children.

During today's visit, LPA and licensee toured the entire home. LPA observed backyard is safe for children, outside backyard is equipped with sufficient toys that are age-appropriate. All dangerous materials are stored on the side yard in an off limits area.

LPA will approve the use of the backyard as of today, 04/06/22.

The hours of operation are from Monday-Friday 8:00am-5pm. DAY CARE AREA: Living Room, dining room (eating only), Bedroom #2, and Bathroom#1, and backyard. OFF LIMITS AREA: Bedroom #1, Bedroom #3, Kitchen, Garage, and front yard.

No deficiencies were issued today under Title 22 Division 12 of the California Code of Regulations.

Notice of Site Visit to remain posted for 30 days.

Copy of this report was emailed to the licensee. Signed copy of this report will be kept in the facility file and made available for public review. Desk Duty is available Monday through Friday between 8:00 AM - 5:00 PM at (650) 266-8800. Website for forms and Regulations: www.cdss.ca.gov
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Leslit Tapia-MandujanoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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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