Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430706089
Report Date: 05/12/2016
Date Signed 05/12/2016 12:05:40 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: 82DATE:
05/12/2016
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Kathy HarmonTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Mary Smith met with Director Kathy Harmon and discussed the Unusual Incident Report received in licensing on 04/27/16. Analyst obtained copies of paperwork, and spoke with several staff members. There were no violations cited during the 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: 05/12/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2016
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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