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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414541
Report Date: 07/15/2024
Date Signed: 07/15/2024 04:02:05 PM


Document Has Been Signed on 07/15/2024 04:02 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:TULIP KIDS ACADEMYFACILITY NUMBER:
434414541
ADMINISTRATOR:PUSHPALATHA VENNAFACILITY TYPE:
830
ADDRESS:1279 LAWRENCE STATIONTELEPHONE:
(669) 255-0540
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY:28CENSUS: 19DATE:
07/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Yesenia VelazquezTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mel Matos met with Yesenia Velazquez, director, for an unannounced case management inspection.

LPA observed twelve napping mats in Classroom 1 during today's inspection that have exposed foam. The mats with exposed foam present a potential risk to the health, safety, or personal rights of children in care. Yesenia Velazquez, director, removed the mats from Classroom 1 during today's inspection.

Yesenia states that the Facility will borrow mats from another site to replace the twelve napping removed during today's inspection. Yesenia also states that the Facility will implement a plan to inspect all mats at least once per month to ensure that the napping mats are maintained in a safe condition at all times.

A "Type B" deficiency is being cited on the attached LIC 9099-D. Exit interview conducted and report was reviewed with Director, Yesenia Velazquez. Appeal rights was also provided to Evangeline prior to conclusion of today's inspection.

Notice of site visit was issued and must remain posted for 30 days.
SUPERVISOR'S NAME: Belinda DevallTELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/15/2024 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: TULIP KIDS ACADEMY
FACILITY NUMBER: 434414541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2024
Section Cited
CCR
101239.1(b)(5)

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Napping equipment: Floor mats used for napping shall be: Maintained in a safe condition with no exposed foam. This requirement was not met as evidenced by: LPA Matos observed twelve napping mats in Classroom 1 during today's inspection that have exposed foam.
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Yesenia Velazquez, director, agreed to borrow mats from another site to replace the twelve napping removed during today's inspection and to implement a plan to inspect all mats at least once
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Yesenia Velazquez, director, removed the mats from Classroom 1 during today's inspection. This presents a potential risk to the health, safety, or personal rights of children in care.
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per month to ensure that the napping mats are maintained in a safe condition at all times.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Belinda DevallTELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
LIC809 (FAS) - (06/04)
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