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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415328
Report Date: 11/21/2024
Date Signed: 11/21/2024 03:59:55 PM

Document Has Been Signed on 11/21/2024 03:59 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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:STANFORD MADERA GROVE CHILDREN'S CENTERFACILITY NUMBER:
434415328
ADMINISTRATOR/
DIRECTOR:		KOSTEPEN, KIMBERLYFACILITY TYPE:
830
ADDRESS:751 OLMSTED ROADTELEPHONE:
(650) 721-6632
CITY:STANFORDSTATE: CAZIP CODE:
94305
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 44DATE:
11/21/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:50 PM
MET WITH:Kimberly KostepenTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 11/21/2024 at 2:50pm, Licensing Program Analyst (LPA) Jialing “Julianne” Zhu met with Director Kimberly Kostepen for an unannounced case management inspection for the purpose of clearing a deficiency issued during an annual inspection conducted on 09/13/2024. Also present during the inspection were 22 fingerprint-cleared staff, and 44 children in care. The facility is within ratio and in compliance with capacity regulations today.

One (1) Type B deficiency was issued during the annual inspection on 09/13/2024. See LIC 809 and LIC 809Cs from 09/13/2024 annual inspection for details.

During today's inspection, LPA reviewed requested documents as stated in the Plan of Corrections (POCs). LPA determined the documents meet the requirements to clear the deficiency. Type B deficiency cited is cleared during today's inspection. Proof of Correction Letters were provided.

A Notice of Site Visit was given and must remain posted for 30 days. Exit interview was conducted, report was reviewed, and Appeal Rights were provided to Director Kimberly Kostepen.

Page 1 of 1. End of Report.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Jialing Zhu
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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