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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430709472
Report Date: 05/03/2019
Date Signed: 05/03/2019 04:17:39 PM

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:YMCA-BOOKSINFACILITY NUMBER:
430709472
ADMINISTRATOR:TONI BROWNFACILITY TYPE:
840
ADDRESS:1590 DRY CREEK ROADTELEPHONE:
(408) 265-3588
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:140CENSUS: 33DATE:
05/03/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Kristina OgleTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Mel Matos and Peter Tinkelenberg met with Kristina Ogle, program director, for an unannounced case management inspection. The Facility is located on the campus of Booksin Elementary School in three portables, located behind the community garden, and in Room 24.

LPAs observed one teacher and one aide in Portable 1 with 17 school age children and the assistant director (teacher) and one teacher in Portable 2 with 16 school age children during today's inspection. Portable 3 and Room 24 were not in use during today's inspection due to low enrollment.

Kristina agreed to send updated director paperwork for the new incoming director to LPA Peter Tinkelenberg by Friday May 10, 2019.

No deficiencies issued during today's inspection.


A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019
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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