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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414670
Report Date: 12/17/2021
Date Signed: 12/17/2021 05:46:19 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:ACTION DAY PRIMARY PLUSFACILITY NUMBER:
434414670
ADMINISTRATOR:SCHROEDER, PAULAFACILITY TYPE:
830
ADDRESS:2174 LINCOLN AVENUETELEPHONE:
(408) 266-8188
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:50CENSUS: 24DATE:
12/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Shyla DuarteTIME COMPLETED:
05:55 PM
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Licensing Program Analysts (LPAs) Ofelia Calivo and Marilou Monico met with Shyla Duarte, Site Director, for an unannounced Required 1-year inspection. LPAs toured the facility both indoor and outdoor. LPAs reviewed 11 children's files.

Due to time constraints, LPAs were not able to complete the inspection. LPAs will return some other time.

There were no deficiencies cited.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Ofelia CalivoTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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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