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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413116
Report Date: 10/24/2019
Date Signed: 10/24/2019 01:19:08 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:ABC EVERGREEN PRESCHOOLFACILITY NUMBER:
434413116
ADMINISTRATOR:JENNY YEN HAFACILITY TYPE:
850
ADDRESS:2650 ABORN ROADTELEPHONE:
(408) 791-7772
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:80CENSUS: 50DATE:
10/24/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jenny Yen HaTIME COMPLETED:
01:30 PM
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ON 10/24/19 Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Case Management visit at ABC Evergreen Preschool and met with Director.

ON 10/23/19 during an inspection at the facility, LPA's laptop went into a consistency check and signatures could not be obtained on the reports. LPA returned to the facility, obtained signatures on reports of 10/23/19 and provided them to Director.

This report was reviewed with Director. A NOTICE OF SITE VISIT WAS ISSUED.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2019
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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