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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414541
Report Date: 10/24/2023
Date Signed: 10/24/2023 10:10:41 AM


Document Has Been Signed on 10/24/2023 10:10 AM - 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:
434414541
ADMINISTRATOR:MANIKYAVALLI RAOFACILITY TYPE:
830
ADDRESS:1279 LAWRENCE STATIONTELEPHONE:
(669) 255-0540
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY:28CENSUS: 9DATE:
10/24/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Pushpalatha VennaTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Mel Matos met with Pushpalatha Venna, Director, for an unannounced case management inspection. Purpose of today's inspection: discuss documents that were previously submitted to the Department designating Pushpalatha Venna as the new Director. Pushpalatha states that she was designated director of the Facility as of October 19, 2023.

Additional copies of documents for the Facility file were provided to LPA during today's inspection.

Pushpalatha agreed to submit the following documents to LPA by Friday November 3, 2023.

1) Proof of enrollment for the Preventative Health/Safety course
2) Updated Emergency Disaster Plan (LIC 610)
3) Copy of Mmr & updated flu vaccines

Exit interview conducted and report was reviewed with the Director, Pushpalatha Venna. 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: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
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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