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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
434417025
Report Date:
12/16/2021
Date Signed:
01/11/2022 03:03:28 PM
Document Has Been Signed on
01/11/2022 03:03 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:
PRIMROSE SCHOOL OF CUPERTINO
FACILITY NUMBER:
434417025
ADMINISTRATOR:
MONICA THOMPSON
FACILITY TYPE:
850
ADDRESS:
1002 SOUTH DE ANZA BOULEVARD
TELEPHONE:
(408) 685-7133
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95129
CAPACITY:
130
TOTAL ENROLLED CHILDREN:
130
CENSUS:
0
DATE:
12/16/2021
TYPE OF VISIT:
Office
UNANNOUNCED
TIME BEGAN:
10:30 AM
MET WITH:
Monica Thomas and Simahen Shah
TIME COMPLETED:
12:40 PM
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ON 12/16/2021 LPA Stephanie Collins met with Site Director Monica Thompson and owner Simahen Shah at the San Jose Regional Office. The visit was in response the LIC 184 Notice of Incomplete Application (updated documents or revisions required). Primrose School of Cupertino submitted an Application 200A. for 130 preschool program and Infants Program (24 infants) # 434417026. The following items were reviewed and/or submitted.
A. 3 Criminal Record Statement - for Monica Thompson
A 4. Board Resolution -Required
A. 5 Administrative Organization updated
A. 6 Monthly Operating Statement
A.9 Personnel Report.-Updated (Site Permit for Sima
A.11. Health Screen -for both -Administrator OK/ Director is from same facility
A. 12 Emergency Care and Disaster Plan- Updated
B. 2 Preventive Health Practices Training : Director Reg for Lead - Registration on file
Preventive Health Practices Training for Administer-
Pending
CPR first Aid for Director updated completed 11/6/2021.
CPR Administer :
Pending
B.2: Verifications fOr Director and Administrator
B 3 Job Description ; will add Employee Rights (LIC 9052)
B. 5 In Service Training Plan -Updated
B. 6 Parents handbook Addendum.
Admission Polices
Admission Agreement
B.6 Discipline Policies
B.4 Personnel
End
SUPERVISORS NAME
:
Sandy Knight
LICENSING EVALUATOR NAME
:
Stephanie Collins
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/15/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/15/2021
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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