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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413759
Report Date: 09/13/2019
Date Signed: 09/13/2019 03:38:35 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: 35DATE:
09/13/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Bhawna PatkarTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Mel Matos met with Bhawna Patkar, Licensee representative/director, for an unannounced case management inspection. Purpose of today's inspection: discuss change within corporation.

Bhawna submitted paperwork to LPA Matos prior to today's inspection advising of a change in the Facility name and Corporation name for her one member LLC. Per the CA Secretary of State, the LLC number registered with the state of CA remains the same (#201008410091) and Bhawna states that the only change was the name of the LLC. A copy of the Amendment to Articles of Organization of a LLC filed with the CA Secretary of State was provided to LPA during today's inspection.

LPA advised Bhawna that she will need to submit an Application for a Child Care Center License (LIC 200A) to LPA Matos so that the Facility and Corporation names can be updated.

LPA advised Bhawna that she will receive an updated Facility license reflecting the Facility and Corporation name changes upon receipt of the updated Application for a Child Care Center License (LIC 200A).

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: 09/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2019
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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