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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400032
Report Date: 02/24/2023
Date Signed: 02/24/2023 01:57:02 PM

Document Has Been Signed on 02/24/2023 01:57 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:CALIFORNIA YOUNG WORLD AT SAN MIGUELFACILITY NUMBER:
434400032
ADMINISTRATOR:EMERSON VENTURAFACILITY TYPE:
840
ADDRESS:777 SAN MIGUEL AVENUETELEPHONE:
(408) 738-1385
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 28TOTAL ENROLLED CHILDREN: 28CENSUS: 10DATE:
02/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Emerson VenturaTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Mel Matos met with Emerson Ventura, Director, for an unannounced case management inspection. Purpose of today's inspection: discuss the capacity increase from 28 to 42 school age children and room addition (Room P4) request that the Facility submitted to the Department on January 11, 2023. LPAs Matos and Nelson completed a case management inspection on January 31, 2023 to address the capacity increase/room addition. A fire clearance from the Sunnyvale Department of Public Safety approving the capacity increase to 52 school age children and room addition (Room P4) has been received and is on file.

Emerson was advised on January 31, 2023 that a license for 42 school age children in the following rooms: Portable 1 (P1) and Room P4, will be approved upon receipt of an updated Personnel Report (LIC 500) reflecting that the Facility has sufficient staff to maintain the required staff-children ratio for rooms Portable 1 (P1) and Room P4.

LPA advised Emerson that the Facility will have to "withdraw" the capacity increase request and room addition (Room P4) if the Facility cannot submit an updated Personnel Report (LIC 500) reflecting that the Facility has sufficient staff to maintain the required staff-children ratio for rooms Portable 1 (P1) and Room P4 by April 11, 2023.

Exit interview conducted and report was reviewed with the director, Emerson Ventura. No deficiencies issued during today's inspection. Emerson agreed to forward a copy of today's report to Cathy Boettcher, Licensee representative.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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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