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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416115
Report Date: 08/26/2019
Date Signed: 08/26/2019 04:53:12 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:ARMENTA, JULIE & JIMFACILITY NUMBER:
434416115
ADMINISTRATOR:JULIE & JIM ARMENTAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 466-7002
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:14CENSUS: 11DATE:
08/26/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Jim and Julie ArmentaTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Peter Tinkelenberg and Licensing Program Analyst (LPM) Diana Stephenson made a case management inspection to determine licensee's application update request of location change from 977 Thelma Way, San Jose to 1949 Kilchoan Way, San Jose. LPA and LPM observed 3 school-age and 8 preschool age children, along with assistant Thai Ly.

LPA and LPM met with Licensee Jim Armenta to inquire about the change of address on the application update. According to Licensee Jim Armenta, he incorrectly entered the 1949 Kilchoan address on the application update. Licensee Jim Armenta confirmed that he and his wife continue to reside at 977 Thelma Way and are in fact, renters at this address. Licensee provided a copy of liability insurance which expires on 03/15/2020.

Licensee Jim Armenta clarified that his son rents the house at the 1949 Kilchoan Way address. The son will provide a copy of his rent at the Kilchoan address because he is licensed to care for children at that address. Licensee Julie Armenta is the owner of the 1949 Kilchoan Way house.

No deficiencies were issued. Notice of Site Vist was issued, which must be posted for 30 consecutive days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2019
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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