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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413426
Report Date: 07/22/2021
Date Signed: 07/22/2021 10:19:54 AM

Document Has Been Signed on 07/22/2021 10:19 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:TULIP KIDS ACADEMYFACILITY NUMBER:
434413426
ADMINISTRATOR:EVANGELINE PONCEFACILITY TYPE:
850
ADDRESS:1159 WILLOW AVENUETELEPHONE:
(408) 340-7993
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 67TOTAL ENROLLED CHILDREN: 0CENSUS: 20DATE:
07/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Evangeline PonceTIME COMPLETED:
10:30 AM
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Licensing Program Analysts (LPAs) Mel Matos and Janette Cruz met with Evangeline Ponce, director, for an unannounced case management inspection. Purpose of today's inspection: address reporting requirements re: Unusual Incidents.

The Facility self reported an Unusual Incident in writing (via email: cclsjcc@dss.ca.gov) to the San Jose Child Care District Office on Friday July 2, 2021. The Facility had an outbreak of children/staff vomiting and diarrhea over the weekend of June 26, 2021 and June 27, 2021. The Unusual Incident was not communicated to the San Jose Child Care District Office via telephone within 24 hours as required by Title 22 regulations.

The Facility was deep cleaned on Sunday June 27, 2021 and the Facility reopened on Monday June 28, 2021. Children and staff affected by the outbreak were not allowed to return to the Facility until they were clear of symptoms for at least 24 hours.

LPAs note that there is no record of any prior deficiencies related to Reporting Requirements on record. LPAs advised Evangeline that a "Technical Violation" is issued today and a copy of the Technical Violation was provided to Evangeline prior to the completion of today's inspection.

No deficiencies issued during today's inspection.


A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2021
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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