Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413319
Report Date: 08/02/2018
Date Signed: 08/07/2018 02:53:56 PM

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:
08/02/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Katia PerezTIME COMPLETED:
10:09 AM
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Unannounced random visit made by Mahvash Behbood. Met licensee Katia, purpose of the visit explained. Present also were 9 day care children four of which under 2 years old, the rest between 2 and 5. Days and hours of operation is M through F from 7:30 AM to 5:30 PM. Inside and outside of the home inspected. children and staff file reviewed.
There are no bodies of water on the property.
Licensee stated there are no gun at home.
Cleaning supplies stored inaccessible to children.
No fire place in day care area. Fire extinguisher is the correct size. Smoke and carbon monoxide are operational. Licensee states the heater and air conditioner work properly.
No stairs, wall heater in the house.
Toys and play equipment are safe and age appropriate.
Telephone is working and the phone number is still the same.
Children were supervised during the visit.
Discussed with licensee children are not to be left in parked vehicles.
Backyard where children play is fenced.
Licensee's roster was up to date. There is emergency information on file for all children in care.
The fire/disaster drill log is updated The last fire drill was in 03/16/2018.
Licensee, her adult niece and her 4 year old son live in the facility. All adult including the helper have criminal record clearance and licensee and her helper have proof of immunization against Pertussis and Measles.
Licensee's CPR and First Aid expires on 01/10/2020, her helper's CPR and First Aid expires in 2019 . Staff are current with their immunization records.

Off limits: Garage, 2 bedrooms, kitchen and the right side yard.

No deficiency noted during today's visit
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2018
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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