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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202793
Report Date: 08/30/2021
Date Signed: 09/01/2021 09:38:52 AM

Document Has Been Signed on 09/01/2021 09:38 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. 350
SAN JOSE, CA 95131
FACILITY NAME:KOEN ARFFACILITY NUMBER:
435202793
ADMINISTRATOR:KOEN, DEREKFACILITY TYPE:
735
ADDRESS:1620 RAVENS PLACE WAYTELEPHONE:
(646) 423-7601
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
08/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Derek KoenTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA), Steve Nguyen, conducted a visit of facility today and met with Administrator(AD), Derek Koen.

LPA discussed the Licensing/ change of address of facility with AD and confirmed that facility is licensed and has been relocated.

No deficiencies were cited per the California Code Title 22.

LPA reviewed report summary with Derek Koen Licensee/ Administrator and a copy of this report provided via email for review and signature purposes.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2021
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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