Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414668
Report Date: 08/24/2016
Date Signed: 08/24/2016 02:42:38 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:HERNANDEZ, MARIA DEL PILARFACILITY NUMBER:
434414668
ADMINISTRATOR:HERNANDEZ, MARIA DEL PILARFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 704-6266
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:14CENSUS: 5DATE:
08/24/2016
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:MariaTIME COMPLETED:
02:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
A case management visit was made to the facility to check on children's supervision. Upon arrived observed one child leaving with her mother. Inside the house observed 3 children in the yard and two napping. Maria was not in the house upon arrival and children were with two staff.
Toured facility and reviewed children and staff's records. Maria and her two staff have current CPR training and cleared F/P. Discussed regulations regarding immunization. They are building a room at the end of their yard. Analyst advised Maria prior to using the additional room, she needs to contact analyst for inspection.
During today's visit , ratio and supervision were correct. The side yards gates were locked and they make sure to keep the front door locked.
No deficiency noted and Notice of site visit was posted.
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)
Page: 1 of 1