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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415230
Report Date: 09/30/2019
Date Signed: 09/30/2019 03:45:56 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:SMITH, JULIE MARIEFACILITY NUMBER:
434415230
ADMINISTRATOR:SMITH, JULIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 207-5640
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY:14CENSUS: 5DATE:
09/30/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Julie Marie SmithTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Mel Matos met with Julie Marie Smith, Licensee, for an unannounced Plan of Correction (POC) inspection. LPA also observed one adult assistant and five (2 infants & 3 preschool) children in the home during today's inspection.

The Licensee was issued one "Type B" deficiency on September 12, 2019 per Section 102418(g) - Immunizations - of Title 22 regulations as a result of an annual/random inspection in which the immunization records of Children #2 & #3 were not present in the children's files reviewed during the inspection.

The Licensee agreed to submit copies of immunization records as well as completed PM 286 cards to LPA Matos by Friday September 27, 2019. LPA reviewed the files of Children #2 & #3 and observed the immunization records and completed PM 286 cards during today's inspection.

LPA conducted an exit interview with the Licensee and advised her that the "Type B" deficiency issued on September 12, 2019 is thus cleared as of today's inspection.

No other deficiencies issued during today's inspection.


A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME, 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: 09/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2019
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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