Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710045
Report Date: 05/11/2018
Date Signed 05/11/2018 04:48:02 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: 27DATE:
05/11/2018
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Lucricia ParkerTIME COMPLETED:
04:50 PM
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LPA Janet Tse met with assistant director Lucricia Parker for a case management inspection today. LPA explained the nature of today's inspection to her. Present were 14 children with two assistant directors, Lucricia Parker and Shruti Srinivasan, in Room 2, and 13 children with two teachers in Room 1.

A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

LPA observed the after school care is operating within ratio and capacity; and children are supervised during the inspection. LPA reviewed four staff files. LPA observed all staffs have the required immunization records in file per SB 792, and have current CPR & 1st certifications. LPA reviewed 10 child's files. LPA observed all child's files contain the LIC 9224 Acknowledgement of Receipt of Licensing Report with parents' signatures for the reports dated 12/05/2017, 10/20/2017, and 09/15/2017.

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: 05/11/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2018
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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