Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710045
Report Date: 09/20/2017
Date Signed 09/20/2017 02:27:17 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:
(650) 325-5350
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:80CENSUS: 29DATE:
09/20/2017
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Shruti SrinivasonTIME COMPLETED:
02:30 PM
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LPA Janet Tse met with director Shruti Srinivason for a case management inspection. During the annual/random inspection on 09/15/2017, the computer experienced a system error, and signatures were lost from the report. The purpose of this visit is to obtain director's signature again for the reports, and to deliver copies of the reports for the inspection conducted on 09/15/2017.

LPA observed 12 children with one teacher and the director in Room 2, and 19 children with two teachers in Room 1 today. The facility evaluation report dated with director's signature was delivered to the director today.

No deficiency was cited. Notice of site visit was issued and must be posted for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2017
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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