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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400052
Report Date: 05/04/2022
Date Signed: 05/04/2022 04:40:35 PM

Document Has Been Signed on 05/04/2022 04:40 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:KIDSPARKFACILITY NUMBER:
434400052
ADMINISTRATOR:ZEPEDA, CHRISTINAFACILITY TYPE:
850
ADDRESS:2858 STEVENS CREEK BLVD. #100TELEPHONE:
(408) 985-2599
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 18DATE:
05/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Lisa AlvaradoTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA), Marilou Monico, met with Site Director, Lisa Alvarado, for a case management inspection in response to an unusual incident that was self-reported by Lisa on May 3, 2022 involving a three-year-old child (C-1) who was picked up at the center by the child's parent and later found at the park unattended. LPA interviewed staff. LPA reviewed and obtained copy of sign in/out sheet and child's identification and emergency information.

There were no deficiencies cited.

NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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