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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
434412615
Report Date:
03/02/2022
Date Signed:
03/02/2022 03:49:20 PM
Document Has Been Signed on
03/02/2022 03:49 PM
- It Cannot Be Edited
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:
BERNARD, LETAVIA
FACILITY NUMBER:
434412615
ADMINISTRATOR:
LETAVIA BERNARD
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(408) 893-4704
CITY:
SANTA CLARA
STATE:
CA
ZIP CODE:
95051
CAPACITY:
14
TOTAL ENROLLED CHILDREN:
14
CENSUS:
0
DATE:
03/02/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:45 PM
MET WITH:
Letavia Bernard
TIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst(LPA) Anna Morales conducted a CASE MANAGEMENT visit and was greeted by Licensee Letavia Bernard. The purpose of this visit is that the Licensee has requested to extend her INACTIVE STATUS until 9/2022.
LPA toured the facility and observed a Carbon Monoxide and smoke detector and a charged Fire Extinguisher. Licensee stated that she would send me a copy of her First Aid card by the end of next week. LPA did not observe any children in care.
Licensee had to leave the facility and tend to an urgent family matter. Licensee requested that LPA send a copy of this report to her personal email that we have on file.
SUPERVISORS NAME
:
Diana Stephenson
LICENSING EVALUATOR NAME
:
Anna Morales
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/02/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/02/2022
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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