Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413591
Report Date: 03/17/2016
Date Signed 03/17/2016 05:02:47 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 CHILD DEVELOPMENT CENTERFACILITY NUMBER:
434413591
ADMINISTRATOR:ELLEN WILLIAMSFACILITY TYPE:
830
ADDRESS:1063 FEWTRELL DRIVETELEPHONE:
(408) 371-9310
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:9CENSUS: 6DATE:
03/17/2016
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Ellen WilliamsTIME COMPLETED:
05:20 PM
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Licensing Program Analyst Mary Smith met with Owner/Administrator Ellen Williams and Director Andrea Gellenter and discussed an Unusual Incident Report that was received in the licensing office on 03/11/16. During today's visit, analyst reviewed the incident report with both the administrator and the director, and Andrea agreed to send any further documentation to the licensing office by next week. At the conclusion of today's visit, LPA determined that proper procedures were followed, and the reported incident was handled in an appropriate manner. There were no violations cited during today's 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: 03/17/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2016
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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