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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710561
Report Date: 02/16/2023
Date Signed: 02/16/2023 10:44:39 AM


Document Has Been Signed on 02/16/2023 10:44 AM - 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: 0DATE:
02/16/2023
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Nora Lacayo & Cathy BoettcherTIME COMPLETED:
09:45 AM
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Licensing Program Analysts (LPAs) Mel Matos and Janette Cruz met with Nora Lacayo, director, and Cathy Boettcher, executive director/Licensee representative, for an announced case management inspection. Purpose of today's inspection: Facility request for a temporary relocation from the existing rooms (Portables A & B) to Rooms P-9 & P-10. Note: The Facility is located on the campus of Ellis Elementary School.

LPAs toured the indoor and outdoor areas of the Facility during today's inspection. Measurements of the indoor and outdoor areas of the Facility were taken during today's inspection.

A fire clearance has not been received from the Sunnyvale Department of Public Safety as of today's inspection. LPAs note that Rooms P-9 and P-10 are not set up for classroom use and thus a follow up inspection will be scheduled for the week of February 24, 2023 to reinspect/remeasure both rooms based on the classroom set up.

Exit interview conducted and report was reviewed with Nora Lacayo, director, and Cathy Boettcher, executive director/Licensee representative. A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
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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