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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413427
Report Date: 12/04/2019
Date Signed: 12/04/2019 01:51:22 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:TULIP KIDS ACADEMYFACILITY NUMBER:
434413427
ADMINISTRATOR:EVANGELINE PONCEFACILITY TYPE:
830
ADDRESS:1159 WILLOW AVENUETELEPHONE:
(408) 340-7993
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:14CENSUS: 5DATE:
12/04/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Evangeline PonceTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Mel Matos met with Evangeline Ponce, director, for an unannounced case management inspection.

LPA reminded Evangeline that the Facility must include the Lead Poisoning Facts Flyer in the enrollment packets for all newly enrolled children. LPA advised Evangeline to check the Department website: www.ccld.ca.gov to obtain a copy of the flyer.

No deficiencies issued during today's inspection.


A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019
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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