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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413759
Report Date: 05/15/2019
Date Signed: 05/15/2019 04:19:37 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:BOOST UP KIDS ACADEMYFACILITY NUMBER:
434413759
ADMINISTRATOR:JYOTI DAWRAFACILITY TYPE:
850
ADDRESS:743 S WOLFE ROADTELEPHONE:
(408) 732-2200
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:86CENSUS: 38DATE:
05/15/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Jyoti DawraiTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Mel Matos met with Jyoti Dawra, director, for unannounced case management inspection. LPA notes that Jyoti Dawra, director, was on her lunch break and arrived 20 minutes after LPA's arrival.

Susmitha Maiti, fully qualified teacher, was in charge and in ratio in the 4's Room and unable to meet with LPA outside the classroom to complete an annual/random inspection. Jyoti Dawra, director, was on her lunch break and arrived 20 minutes after LPA's arrival.

LPA reviewed Susmitha's file and confirmed that she is a fully qualified teacher with current CPR & First Aid certifications (exp: 08/25/2020). LPA toured the Facility and observed two teachers, including Susmitha, with 17 preschool children in the 4's Room and two teachers and one aide with 21 preschool children in the 3's Room during today's inspection.

LPA advised Jyoti that an annual/random inspection will be conducted at a later date.

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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2019
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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