Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412177
Report Date: 02/19/2016
Date Signed 02/19/2016 02:11:39 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:CLUB J AT THE OSHMAN FAMILY JCCFACILITY NUMBER:
434412177
ADMINISTRATOR:MALLARE, CYRUSFACILITY TYPE:
840
ADDRESS:3921 FABIAN WAYTELEPHONE:
(650) 223-8788
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:154CENSUS: 23DATE:
02/19/2016
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Cyrus MallareTIME COMPLETED:
02:30 PM
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LPA Barbara Walker met with director to discuss two incident reports received. Present were 3 staff and 23 school age children were present today.

LPA Walker reviewed the grassy area and found no hazardous structures or equipment. The area is an open field with 2 benches. LPA Walker also inspected room G103, interviewed director and staff that was present at time of incident. The room is use mainly for building Lego's and block. Nothing hazardous in the classroom.

Based on the information gathered, no deficiencies cited.


The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.

NOTICE OF SITE VISIT ISSUED, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Barbara WalkerTELEPHONE: (408) 334-8553
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2016
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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