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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421388
Report Date: 05/12/2023
Date Signed: 05/12/2023 04:01:29 PM

Document Has Been Signed on 05/12/2023 04:01 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 EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:PRIMROSE SCHOOL OF PLEASANTONFACILITY NUMBER:
013421388
ADMINISTRATOR:NICOLE CUSTINOFACILITY TYPE:
850
ADDRESS:7110 KOLL CENTER PARKWAYTELEPHONE:
(925) 600-7745
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY: 112TOTAL ENROLLED CHILDREN: 112CENSUS: 89DATE:
05/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:NIcole CustinoTIME COMPLETED:
04:00 PM
NARRATIVE
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On 5/12/2023 at approximately 9:15 am Licensing Program Analyst (LPA) Lorraine Dacanay Breaux met with Director, Nicole Custino for a Subsequent Visit Complaint visit to investigate a complaint that was filed against the facility. Facility is dual licensed and holds a license for infants (013421389). Present during the visit were thirty-two 89 preschool age children and 8 teachers.

During the file review, LPA observed incomplete files for eight (8) staff members such as: Mandated Reporter training, applications, Heath History, Immunization record and TB Clearance. S1, S2, S3, S4, S5, S6, S7, S8 (see LIC811)

California Code of Regulations, Title 22 is being cited on the attached LIC 809D. Failure to submit Proof of Corrections (POC) by Plan of Correction date may result in civil penalties.

A notice of site visit was given to director and must be posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
Exit interview conducted and report was reviewed with Nicole Custino.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/12/2023 04:01 PM - It Cannot Be Edited


Created By: Lorraine Dacanay-Breaux On 05/12/2023 at 03:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: PRIMROSE SCHOOL OF PLEASANTON
FACILITY NUMBER: 013421388

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2023
Section Cited
CCR
101216(g)(1)

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(g) All personnel...shall be in good health...(1)... good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.
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Director will make sure to obtain LIC503 Health Screening Report from all teachers, and verification of a tuberculosis test. Director will submit documents and a statement to LPA Dacanay Breaux, by POC date, and explaining how the facility will ensure staff files are complete at all times.
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This requirement was not met as evidenced by: staff did not have a Health Screening Report on file, were missing proof of tuberculosis test. This poses a potential risk to the health and safety of the children in care.
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Type B
05/26/2023
Section Cited
CCR1596.7995(g)(1)

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(a)(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles...
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Director will make sure to obtain immunization records for current and new hired staff. Director will submit statement to LPA, by POC date, explaining how the facility will ensure completed staff files moving forward. Director will also submit completed immunization records to LPA.
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This requirement was not met as evidenced by: Staff is missing immunization record for MMR and TB. This poses a potential risk to the health and safety of the children in care.
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Director will take Record Keeping Orentation
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Chandra Charles
LICENSING EVALUATOR NAME:Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023


LIC809 (FAS) - (06/04)
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