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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413427
Report Date: 09/13/2022
Date Signed: 09/13/2022 12:14:03 PM


Document Has Been Signed on 09/13/2022 12:14 PM - It Cannot Be Edited

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: 9DATE:
09/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Patssy RodriguezTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Mel Matos met with Patssy Rodriguez, administrative assistant, for an unannounced case management inspection. Evangeline Ponce, director, was out ill and thus not present during today's inspection.

LPA provided a copy of the safe sleep regulations to Patssy during today's inspection. LPA advised Patssy that an annual inspection of the infant program will be conducted at a later date.

Exit interview conducted and report was reviewed with Patssy Rodriguez, administrative assistant. No deficiencies issued during today's inspection.

A Notice of Site Visit was given 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: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
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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