Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710045
Report Date: 07/14/2016
Date Signed 07/14/2016 03:20:45 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:WALTER HAYS KIDS' CLUBFACILITY NUMBER:
430710045
ADMINISTRATOR:CHASE, CHRISTINAFACILITY TYPE:
840
ADDRESS:1525 MIDDLEFIELD ROADTELEPHONE:
(415) 325-5350
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:80CENSUS: 27DATE:
07/14/2016
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Julian HuynhTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA), Marilou Monico, met with Site Director, Julian Huynh, for a case management visit. During today's visit, LPA interviewed Site Director.

As a result of this visit, there are no deficiencies cited.

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2016
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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