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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410869
Report Date: 07/29/2019
Date Signed: 07/29/2019 12:03:44 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:OU, LIDANFACILITY NUMBER:
434410869
ADMINISTRATOR:OU, LIDANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 366-2607
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:14CENSUS: 13DATE:
07/29/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Lidan OuTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA), Marilou Monico, conducted a Plan of Correction (POC) inspection. Licensee was cited on July 17, 2019 under Staffing Ratio and Capacity. LPA met with Licensee, Lidan Ou, and explained the nature of today's inspection. Also present in the home were licensee's adult daughter, and 13 children including 12 preschool age and one school age. LPA observed that parents/authorized representatives completed and signed the Acknowledgement of Receipt of Licensing Report (LIC 9224).

Deficiency under Staffing Ratio and Capacity is hereby corrected and cleared.

There were no deficiencies cited.

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2019
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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