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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413739
Report Date: 06/17/2020
Date Signed: 06/17/2020 12:08:55 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:BAXTER, KRISTIN & JEFFREYFACILITY NUMBER:
434413739
ADMINISTRATOR:KRISTIN & JEFFREYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 568-5484
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:14CENSUS: 5DATE:
06/17/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kristin BaxterTIME COMPLETED:
12:30 PM
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LPA Janet Tse met with licensee Kristin Baxter via a tele-inspection for a Case Management visit to deliver an amended facility evaluation report. LPA explained the nature of today's inspection to Licensee. LPA observed five children including one infant with Licensee in the home today.

An amended facility evaluation report for the inspection conducted on 03/13/2020 is delivered via email to Licensee today.

No deficiency was cited. Notice of site visit was issued and must be posted for 30 days.

Due to COVID 19, a copy of this Licensing report with LPA's signature alone will be emailed to Licensee; and in lieu of Licensee's signature, a read receipt of the email will serve as acknowledgement of receipt of this Licensing report by Licensee.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2020
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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