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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400287
Report Date: 09/26/2019
Date Signed: 09/26/2019 01:55:49 PM

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:GOOD SAMARITAN ED. & ENRICHMENT PROGRAMSFACILITY NUMBER:
434400287
ADMINISTRATOR:WONG, LORETTAFACILITY TYPE:
830
ADDRESS:19624 HOMESTEAD ROADTELEPHONE:
(408) 996-8290
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:24CENSUS: 18DATE:
09/26/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Guadalupe CoriaTIME COMPLETED:
02:05 PM
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Licensing Program Analysts (LPAs), Marilou Monico and Pete Hernandez, made a case management inspection to obtain signature on the LIC421BG (Civil Penalty Assessment - Caregiver Background Check) and to provide the facility printed copies of Facility Evaluation Report dated 09/25/19 . This was due to computer consistency issue.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2019
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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