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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416895
Report Date: 06/26/2024
Date Signed: 06/26/2024 04:56:59 PM

Document Has Been Signed on 06/26/2024 04:56 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:LUGO, ANDREAFACILITY NUMBER:
434416895
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
06/26/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Andrea LugoTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Samantha Yip conducted an announced pre-licensing inspection. LPA met with Applicant Andrea Lugo and explained the reason for the inspection. The purpose of this inspection is to follow-up on the pending items that needed to be completed from the pre-licensing inspection dated 06/12/2024.

During today's inspection, LPA observed that the laundry room was taken down and the deck flooring was rebuilt. LPA also observed that the see-saw was anchored to the ground. LPA also checked the pack-n-plays and observed that the mattress were flat. LPA discussed with Applicant that mattress needs to fit the pack-n-play.

LPA discussed with Applicant that she needs to report to Licensing of any alternation or add-ons that will be done to the home prior to it be started and that to check with the City regarding building permits.

An updated LIC 999A-Yard was obtained during today's inspection.

Applicant submit proof that film was installed on the window in the restroom.

Exit interview conducted and report was reviewed with Applicant Andrea Lugo.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
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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