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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408862
Report Date: 05/03/2019
Date Signed: 05/10/2019 09:18:54 AM

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:GOOGLE'S CHILDREN'S CENTER AT THE WOODSFACILITY NUMBER:
434408862
ADMINISTRATOR:MARILYN GRAVESFACILITY TYPE:
830
ADDRESS:325 GLADYS AVENUETELEPHONE:
(650) 526-6337
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94043
CAPACITY:112CENSUS: 59DATE:
05/03/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Marilyn GravesTIME COMPLETED:
03:25 PM
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Note: This report was made after the inspection due to a system error that resulted into LPA was unable to issue a report in FAS on site. An 809-S report was provided to Director at the time of visit. This report will be mailed to the facility for record and for obtaining director's signature.

Licensing Program Analyst (LPA), Oscar Huang, met with Director Marilyn Graves for a case management inspection in response to an unusual incident that was reported by the facility on April 25, 2019. The incident occurred on April 24, 2019 involving a ten-month old infant. LPA toured the facility, interviewed staffs, and reviewed the infant files. Based on interviews with the staffs and file reviews, LPA concluded that the facility and staffs had managed the urgent situation properly by observing the incident and promptly call 911 for medical treatment on an allergic reaction infant after serving the snack. The infant has no known allergies, neither had the parents, nor Physician's Report, Child's Preadmission Health History-Parents Report, Infant Needs and Service Plan indicated and informed such. The infant returned to the facility on the next day, and is scheduled to visit an allergist.

No Deficiency was cited. Exit interview conducted with Director. A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: (408) 334-8321
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2019
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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