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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413426
Report Date: 09/29/2021
Date Signed: 09/29/2021 03:55:39 PM

Document Has Been Signed on 09/29/2021 03:55 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: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: 31DATE:
09/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Evangeline PonceTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Mel Matos met with Evangeline Ponce, director, for unannounced case management inspection. LPA toured the Facility both indoor and outdoor areas of the Facility during today's inspection.

LPA reminded Evangeline that all children two years and older and all adults must wear face coverings, except during eating and napping, per the guidance from the Santa Clara County Public Health Department and California Department of Public Health. Evangeline understands that the Facility must adhere to the guidance issued by the public health department regarding face coverings at all times.

LPA advised Evangeline that failure to comply with the face covering mandate will result in the issuance of a Type A deficiency.

No deficiencies issued during today's inspection.


A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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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