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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414750
Report Date: 11/02/2022
Date Signed: 11/02/2022 10:09:40 AM


Document Has Been Signed on 11/02/2022 10:09 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:SSD STATE PRESCHOOL-LAKEWOODFACILITY NUMBER:
434414750
ADMINISTRATOR:STACY GUMFORY-ESQUIBELFACILITY TYPE:
850
ADDRESS:750 LAKECHIME DRIVETELEPHONE:
(408) 522-8213
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY:48CENSUS: 37DATE:
11/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Grissel RamirezTIME COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) Mel Matos met with Grissel Ramirez, administrative assistant, for an unannounced case management inspection. Purpose of today's case management inspection: discuss paperwork that was submitted to the San Jose Child Care District Office designating current director Stacy Gumfory-Esquibel as the new Licensee representative for the Sunnyvale School District.

LPA requested that the following forms be updated/corrected and resubmitted:

1) Designation of Facility Responsibility (LIC 308): Needs to list a "fully qualified teacher" as the designated person when Stacy Gumfory-Esquibel (Licensee representative/director) is not present on site.

2) Personnel Report (LIC 500): Must list all preschool staff working at the Facility.

3) Emergency Disaster Plan (LIC 610): Must list all "emergency exits", "staff assignments" and utility shut-off locations.

Grissel states that she will follow up with Stacy Gumfory-Esquibel and submit the updated forms to the San Jose Child Care District Office by Thursday November 10, 2022.

Exit interview conducted and report was reviewed with Grissel Ramirez, administrative assistant. No deficiencies issued during today's inspection.

Notice of site visit issued 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: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
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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