Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430706089
Report Date: 05/10/2016
Date Signed 05/10/2016 03:40:30 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:CAMPBELL CHRISTIAN EARLY CHILDHOOD CENTERFACILITY NUMBER:
430706089
ADMINISTRATOR:KATHY HARMONFACILITY TYPE:
850
ADDRESS:1075 WEST CAMPBELL AVE.TELEPHONE:
(408) 370-4900
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:116CENSUS: 97DATE:
05/10/2016
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Shawn StuartTIME COMPLETED:
03:50 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
Licensing Program Analyst (LPA) Mary Smith met with Supervisor Shawn Stuart and discussed the details of an Unusual Incident Report that was sent to licensing, and received on 04/27/16. The Director of the Preschool was out for the day, and because analyst will be gathering further information when meeting with her at a later date, the visit will be continued. There were no violations cited during today's visit.

A Notice of Site Visit was posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Mary SmithTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2016
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