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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414750
Report Date: 09/17/2020
Date Signed: 09/17/2020 02:03:05 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:SSD STATE PRESCHOOL-LAKEWOODFACILITY NUMBER:
434414750
ADMINISTRATOR:KIM ANH LEFACILITY TYPE:
850
ADDRESS:750 LAKECHIME DRIVETELEPHONE:
(408) 522-8213
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY:48CENSUS: 0DATE:
09/17/2020
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Linda Van MouwerikTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Mel Matos conducted an announced tele-case management inspection of the Facility via video call (Skype). LPA met with Linda Van Mouwerik, Licensee representative, and explained to her that due to the COVID-19 situation and "Shelter in Place" Order, today's Facility Evaluation Report (LIC 809) is being generated remotely and will be emailed to her upon the completion of today's tele-case management inspection. Linda's reply to the email will serve as acknowledgement that the report was received.

Purpose of today's tele-case management inspection: The Facility is requesting to add Room P1 to the existing license. The capacity remains unchanged. Hours of operation: 8:15 AM to 11:15 AM and 12 PM to 3 PM Monday to Friday.

The Facility is currently licensed in the following rooms: Rooms P2 & Y3. Measurements for Rooms P1, P2, and Y3 are as follows:

ROOM P1: 39.083 x 26.833 = 1,048.714 (minus 5.000 x 2.000 = 10.000) = 1,038.714

ROOM P2: 39.083 x 26.833 = 1,048.714 (minus 5.000 x 2.000 = 10.000) = 1,038.714

ROOM Y3: 39.000 x 23.000 = 897.000 (minus 9.417 x 13.500 = 127.129) = 769.871

TOTAL INDOOR CLASSROOM SPACE: 2,847.299 sq. ft. divided by 35 = 81 preschool children.

There is sufficient sinks, toilets, chairs, tables, cubbies and equipment for the children within all three rooms. The playground measurements (last measured on August 29, 2018) remain unchanged. A fire clearance approval from the Sunnyvale Department of Public Safety was received prior to today's tele-case management inspection.

LPA conducted an exit interview and advised Linda that the license for 48 preschool children in Rooms P1, P2, and Y3 is approved effective today, September 17, 2020.

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: 09/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020
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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