Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410509769
Report Date: 10/22/2015
Date Signed 10/22/2015 04:49:29 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:CSSF REC DEPT-SIEBECKER CENTERFACILITY NUMBER:
410509769
ADMINISTRATOR:GONZALEZ, DIANAFACILITY TYPE:
850
ADDRESS:510 ELM COURTTELEPHONE:
(650) 875-6979
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:55CENSUS: DATE:
10/22/2015
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Laura Armanino, Kelli Jo CullinanTIME COMPLETED:
05:00 PM
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LPA Andrea Medlin met with preschool coordinator and recreation and community services supervisor for this case management visit. The purpose of this visit is due to facility requesting an outdoor playground waiver to use the adjacent public playground. LPA inspected all outdoor play areas and all are age appropriate. Facility has exclusive use during their scheduled times. Facility has submitted a waiver for the outdoor playground.

This report was reviewed with recreation and community services supervisor and a copy of this report must be made available to the public upon request.

Notice of Site Visit shall remain posted for 30 days.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8843
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2015
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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