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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416683
Report Date: 10/12/2021
Date Signed: 10/12/2021 05:08:10 PM

Document Has Been Signed on 10/12/2021 05:08 PM - 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:ONE WORLDFACILITY NUMBER:
434416683
ADMINISTRATOR:ANNA SIFUENTESFACILITY TYPE:
850
ADDRESS:8387 WREN AVENUETELEPHONE:
(408) 842-4148
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 38TOTAL ENROLLED CHILDREN: 35CENSUS: 18DATE:
10/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Anna SifuentesTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Samantha Yip conducted a Case Management- Other inspection. LPA met with Licensee Anna Sifuentes and explained the reason for the inspection. The purpose of this inspection was LPA observed that S-1 was present at the facility, but was not associated to facility roster.

S-1 has cleared criminal record and child abuse index clearance. Licensee submitted LIC 9182 and a valid ID for S-1 to LPA on 08/23/2021 via email. LPA reminded Licensee to follow-up with Licensing to ensure that all staff's fingerprints are cleared and/or transferred. LPA also stated that she can send all LIC 9182 and a valid ID to cclsjcc@dss.ca.gov. LPA stated that she will have S-1's fingerprints transferred.

As a result of this inspection, no deficiencies were cited as a result of this investigation. An exit interview was conducted where this report was discussed and provided to Licensee Anna Sifuentes. A Notice of Site Visit has been issued and must be posted for 30 consecutive days.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2021
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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