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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434404301
Report Date: 01/11/2022
Date Signed: 03/28/2022 09:50:41 AM

Document Has Been Signed on 03/28/2022 09:50 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:ASSOCIATED STUDENTS CHILD DEVELOPMENT CENTERFACILITY NUMBER:
434404301
ADMINISTRATOR:HEATHER VISEFACILITY TYPE:
850
ADDRESS:460 SOUTH EIGHTH STREETTELEPHONE:
(408) 924-6988
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 36DATE:
01/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jane Zamora/Heather ViseTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Anna Morales conducted a CASE MANAGEMENT VISIT in regards to an incident that occurred on 1/5/2022. This incident was self -reported by the facility to CDSS San Jose Regional Office on 1/6/2022.

The incident that occurred on 1/5/2022 in one of the classroom during the classroom's nap time and during outdoor activities. There were approximately 15 children and two staff present during the time of both incidents. LPA interviewed the Director, Teacher and teacher's aid and other parties involved. LPA toured the classroom and playground.

EXIT INTERVIEW WAS CONDUCTED AND REPORT WAS REVIEWED WITH THE DIRECTOR. NO DEFICIENCIES WERE CITED.

NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAY
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2022
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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