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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710561
Report Date: 06/29/2022
Date Signed: 06/29/2022 03:02:37 PM


Document Has Been Signed on 06/29/2022 03:02 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:CALIFORNIA YOUNG WORLD AT ELLISFACILITY NUMBER:
430710561
ADMINISTRATOR:JOSEPHINE FELIXFACILITY TYPE:
840
ADDRESS:550 EAST OLIVE STREETTELEPHONE:
(408) 774-0405
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:56CENSUS: 21DATE:
06/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Nora LacayoTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA), Mel Matos, met with Nora Lacayo, director, for an unannounced case management inspection. LPA notes that the Facility is located on the campus of Ellis Elementary School in Portables A & B. Purpose of today's inspection: discuss construction project on the campus of Ellis Elementary School.

Nora states that the elementary school campus is under construction at this time since the school district is rebuilding the entire elementary school. Nora states that the Facility is unaffected at this time since the phase of relocating the Facility to another part of campus is not scheduled until the Fall of 2023.

LPA toured the campus area closest to the Facility and observed that the areas under construction are fenced off and children don't have access to those parts of campus.

LPA advised Nora that the Facility must submit updated Facility/campus sketches (indoor/outdoor) of the area(s) of the elementary school campus that the Facility is scheduled to be relocated to once there is a definite date(s) regarding the relocation process. LPA also advised Nora that the Facility will not be allowed to operate in the new area(s) of the elementary school campus until an approved fire inspection has been received and a follow up inspection has been completed by the Department.

Nora states that she understands LPA's explanation and will also provide a copy of today's report to her superiors.

No deficiencies issued during today's inspection. Exit interview conducted and report was reviewed with Nora Lacayo, director.

Notice of site visit issued and must remain posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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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