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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412550
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:34:42 PM

Document Has Been Signed on 09/18/2024 04:34 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:HEDMAN, ANNEFACILITY NUMBER:
434412550
ADMINISTRATOR/
DIRECTOR:		ANNE HEDMANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 838-9682
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
09/18/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:04 PM
MET WITH:Anne HedmanTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management-Licensee Initiated inspection. LPA met with Licensee Anne Hedman and explained the reason for the inspection. The purpose of this inspection is Licensee is requesting to change rooms.

Licensee requested to make bedroom #3 on-limit and make bedroom #1 off-limits. An updated fire clearance was granted on 09/11/2024. LPA inspected bedroom #3 and observed that it was safe for the children. The off-limit areas inside of home are bedroom #1, bedroom #2, and kitchen.

The LIC 279 was obtained during today's inspection.

No deficiencies were issued as a result of this inspection. Exit interview conducted and report was reviewed with Licensee Anne Hedman. A notice of site visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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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