Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413319
Report Date: 08/24/2016
Date Signed: 08/24/2016 10:54:34 AM

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:PEREZ PALMA, KATIAFACILITY NUMBER:
434413319
ADMINISTRATOR:PEREZ PALMA, KATIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 283-3805
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:14CENSUS: 9DATE:
08/24/2016
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Evelyn Cabrera & Katia PerezTIME COMPLETED:
11:00 AM
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A follow up visit was made tot he facility to check on deficiencies cited on 07/05/2016.
Upon arrival Katia was not home and Evelyn stated that she is at Safeway.
Later Katia arrived and stated that she was at a pharmacy. Analyst advised her that during each of my visit she was not home. I advised her the regulation that she needs to be home 80% of the time and could not have an outside job. Katia stated that she is home all the times.
Reviewed children's records which all were up to date. Discussed hand washing procedure with Katia.
Notice of site visit was posted. Notice must be up for 30 days.
Deficiencies cited have been cleared.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2016
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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