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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430752951
Report Date: 02/28/2022
Date Signed: 03/01/2022 09:32:10 AM


Document Has Been Signed on 03/01/2022 09:32 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/01/2022 09:18 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

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Licensing Program Analyst (LPA) Samantha Yip and Regional Manager (RM) Tony Studebaker conducted an unannounced, Case Management - Other, inspection to serve the Order to Licensee/Facility of Immediate Exclusion from Facility for Harry Eugene Goularte. Licensee's spouse, Paul Bender stated that the daycare was not in operation. RM served Licensee's spouse, Paul Bender with an Order to Licensee/Facility of Immediate Exclusion from Facility and the Immediate Exclusion Order for Harry Eugene Goularte. RM left the sealed exclusion letter for Harry. RM also provided and reviewed the LIC995B, "Family Child Care Home Addendum to Notification of Parents' Rights (Regarding Removal/Exclusion)”. RM advised Paul that LIC 995B needs to provided to each parent. Paul was uncomfortable signing any documents, since he is not part of the daycare, but will pass them to Licensee Patty.

No deficiencies were issued. Exit interview conducted and report was reviewed with Licensee's spouse, Paul Bender.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
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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