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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416364
Report Date: 06/27/2022
Date Signed: 07/12/2022 09:50:37 AM


Document Has Been Signed on 07/12/2022 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:EXCELSIOR PRESCHOOL CUPERTINO, LLCFACILITY NUMBER:
434416364
ADMINISTRATOR:TINA TAITFACILITY TYPE:
850
ADDRESS:20299 STEVENS CREEK BOULEVARDTELEPHONE:
(669) 281-2188
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:48CENSUS: DATE:
06/27/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Janel Martinez TIME COMPLETED:
12:45 PM
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Office visit with Janel Martinez to review the application for a center, the following items need to be corrected or updated prior to a preclicensing inspection and final approval of a license.

1. LIC 200
2. LIC 309
3. Board Resolution needs to be updated to appoint Janel Martinez as liaison.
4. LIC 401 needs to be updated
5.'LIC 403 needs to be updated.
6. LIC 403 a needs to be submitted.
7.Lease needs to be between our applicant Excelsior Preschool Cupertino LLC.
8. Job descriptions need to be updated.
9. Employee Handbook needs to be updated.
10. Staff Training needs updating.
11. LIC 999 needs updating.
12. LIC 610 needs updating.
13. Admission Agreement needs updating.
14. Parent Handbook needs updating.
15. Director needs a more current TB test.


A more detailed list of corrections was given to Janel Martinez. Ms. Martinez will submit the outstanding items by July 8, 2022. .
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
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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