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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400049
Report Date: 08/16/2019
Date Signed: 08/16/2019 04:13:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:COUNTRY DAY LITTLE SCHOOLFACILITY NUMBER:
434400049
ADMINISTRATOR:PEGGY JANE TRIULZIFACILITY TYPE:
850
ADDRESS:3990 VENTURA COURTTELEPHONE:
(650) 494-8044
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:40CENSUS: 10DATE:
08/16/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Peggy Jane TriulziTIME COMPLETED:
04:20 PM
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Licensing Program Analysts (LPAs), Marilou Monico and Dung Mac, met with Site Director, Peggy Jane Triulzi, regarding an unusual incident reported to Licensing on July 17, 2019. During today's inspection, LPAs toured the facility, interviewed staff, and reviewed file. Copy of children's roster was obtained.

There were no deficiencies cited.

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 334-8549
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 277-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2019
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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