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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430709448
Report Date: 10/21/2020
Date Signed: 11/04/2020 11:19:56 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:PRIMARY PLUS - INFANTSFACILITY NUMBER:
430709448
ADMINISTRATOR:LOPEZ, LORENAFACILITY TYPE:
830
ADDRESS:18720 BUCKNALL ROADTELEPHONE:
(408) 370-0350
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY:83CENSUS: DATE:
10/21/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Lorena LopezTIME COMPLETED:
12:00 PM
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This is verification that an amended Case Management report was delivered on 10/20/2020.

An exit interview was conducted with the Director Lorena Lopez. The inspection was done by using Video Conference, this report has been delivered and reviewed by e-mail and verified by "return receipt." in lieu of a physical delivery and signature.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
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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