Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002281
Report Date: 06/26/2017
Date Signed 06/26/2017 04:02:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PUREVDORJ, TUULFACILITY NUMBER:
384002281
ADMINISTRATOR:PUREVDORJ, TUULFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 513-2159
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94118
CAPACITY:14CENSUS: 9DATE:
06/26/2017
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Tuul PurevdorjTIME COMPLETED:
04:10 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
LPA Huang met with Licensee Tuul Purevdorj for a POC inspection today at this facility. Purpose of the inspection was explained to the Licensee. There were two helpers with 9 children in care today, 3 of them were infants. Licensee has proof of all required immunization record for all staff today. Licensee stated that she has mailed the record to CCL. LPA checked the record and found that LPA received in the office. LPA scheduled the inspection and forgot that Licensee already mailed in. Deficiency was cleared in 6/9/17.



This report was explained to the Licensee, Notice of site visit was posted.
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Karen HuangTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2017
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