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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415545
Report Date: 05/17/2022
Date Signed: 05/17/2022 11:01:57 AM

Document Has Been Signed on 05/17/2022 11:01 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:SIVIRA GALLARDO, GIOVANNAFACILITY NUMBER:
434415545
ADMINISTRATOR:SIVIRA GALLARDO, GIOVANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 512-0244
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
05/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Andres ServaTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Mel Matos conducted an unannounced case management inspection and met with Andres Serva, Licensee's spouse. Andres states that Giovanna Sivira Gallardo, Licensee/spouse, is currently hospitalized due to health issues and thus unavailable. LPA did observe three adult assistants and nine day care children (1 infant & 8 preschool) in the home during today's inspection. Andres states that all three adult assistant have CPR/First Aid certifications.

Andres states that Giovanna should be released from the hospital within a few days. Andres states that Giovanna will contact LPA once she is back home from the hospital.

No deficiencies issued during today's inspection.

Notice of site visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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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