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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710436
Report Date: 11/01/2019
Date Signed: 11/01/2019 10:05:56 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:SCOTT LANE STATE PRESCHOOLFACILITY NUMBER:
430710436
ADMINISTRATOR:YIN YEE LEUNGFACILITY TYPE:
850
ADDRESS:1925 SCOTT BLVDTELEPHONE:
(408) 423-4117
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:72CENSUS: 53DATE:
11/01/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Kim VoTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Tuoc Doan conducted an unannounced inspection of the Preschool to investigate an incident involving Child 1. LPA met with the Teachers in Room 34 Kim Vo and Deborah Hildago and explained to them the purpose of the site visit.

Facility had reported to Community Care Licensing Office the following:
On 10/11/19 Child 1's parent informed staff at the school about a concern that the parent has after Child 1 told the parent about an incident that may have happened that involved Child 1 and Child 2.

LPA conducted interviews with the Teachers and Child 1's parent. LPA observed the children and staff as they engage in their daily activities. Records were also reviewed and copies were obtained.

In the areas that were evaluated, no regulatory violations were observed at the time of the visit.

Exit Interview was conducted, where this report was reviewed with Teacher Kim Vo.

A NOTICE OF SITE VISIT WAS ISSUE AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2019
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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