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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416304
Report Date: 05/19/2021
Date Signed: 05/21/2021 06:25:25 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:REHOBOTH PRESCHOOL/DAYCAREFACILITY NUMBER:
434416304
ADMINISTRATOR:MERAT AYALEWFACILITY TYPE:
840
ADDRESS:3275 WILLIAMS ROADTELEPHONE:
(408) 603-5251
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY:40CENSUS: DATE:
05/19/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Merat Ayalew, Applicant RepresentativeTIME COMPLETED:
03:45 PM
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Licensing Program Manager (LPM) Sandy Knight, and Licensing Program Analyst (LPA) conducted a scheduled office meeting at the San Jose Regional Office with Merat Ayalew, Applicant Representative.

During today's meeting, Merat submitted the following updated documents:
  1. List of toys and equipment

LPM and LPA conducted an exit Interview and advised Merat that a license for 40 School-age children will be effective 5/20/2021.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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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