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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
198001061
Report Date:
09/22/2022
Date Signed:
09/22/2022 08:26:36 AM
Document Has Been Signed on
09/22/2022 08:26 AM
- 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
,
1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK
,
CA
91754
FACILITY NAME:
KIDS KLUB PASADENA
FACILITY NUMBER:
198001061
ADMINISTRATOR:
VIVIAN CHANG
FACILITY TYPE:
830
ADDRESS:
380 SO. RAYMOND STREET
TELEPHONE:
(626) 795-2501
CITY:
PASADENA
STATE:
CA
ZIP CODE:
91105
CAPACITY:
55
TOTAL ENROLLED CHILDREN:
55
CENSUS:
20
DATE:
09/22/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
08:00 AM
MET WITH:
Krystal Ramirez, Infant Coordinator
TIME COMPLETED:
08:35 AM
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LPA Vasquez conducted a case management to obtain signatures for an amendment on 09/22/22.
SUPERVISORS NAME
:
Claudia Guangorena
LICENSING EVALUATOR NAME
:
Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/22/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/22/2022
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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