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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421388
Report Date: 06/07/2023
Date Signed: 06/07/2023 03:51:47 PM

Document Has Been Signed on 06/07/2023 03:51 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: 81DATE:
06/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Nicole Custino TIME COMPLETED:
04:15 PM
NARRATIVE
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On 06/07/2023 at approximately 1:30am, Licensing Program Analysts (LPAs) Lorraine Dacanay Breaux and Jaleesa Jackson visited the facility for the purpose of conducting a complaint allegation. The unannounced complaint investigation and a subsequent Case Management inspection and met with Director, Nicole Custino. Also present at the time of the inspection was eighty-one (81) children and 13 additional staff in 5 classrooms. LPAs conducted a health and safety inspection of the facility.

During record review of the complaint, LPAs found that one former staff member did not have an eligible background clearance. The issuance of a Type A Violation is being issued today and the assessment of an immediate $500.00 civil penalty. See LIC9099-D.

During record review of the complaint, LPA interviewed director, an incident was not reported to parent(s) or Department of Social Services. Type B Violation was cited (see LIC9099)

LPAs Dacanay Breaux and Jackson informed facility representative, Nicole Custino that this report dated 06/07/23 documents one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk to the health, safety, or personal rights of children in care.

Also, LPAs Dacanay Breaux and Jackson informed the facility representative to provide a copy of this licensing report dated 06/07/2023 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Notice of Site Visit and Appeal Rights were given. Notice of Site Visit must be posted for 30 days. Failure to comply with posting requirements will result in the issuance of an immediate $100 civil penalty. Exit interview conducted and report was reviewed with the director, Nicole Custino.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2023
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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Document Has Been Signed on 06/07/2023 03:51 PM - It Cannot Be Edited


Created By: Lorraine Dacanay-Breaux On 06/07/2023 at 02:07 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: 06/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2023
Section Cited
CCR
101170(e)(1)

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101170 - Criminal Record Clearance: (e) All individuals subject to a criminal record review shall prior to working, residing, or volunteering in a licensed facility; (1) Obtain a criminal record clearance or a criminal record exemption as required by the Department.
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During the complaint investigation, inspection, a former staff that was hired 2/27/23 this staff did not have an eligible criminal background clearance.

Staff was terminate on 04/24/23.
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This requirement was not met as evidenced by: LPAs observed a former staff did not have eligible clearance which is an immediate health, safety, and personal rights risk to children in care.
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Type B
06/16/2023
Section Cited
CCR101212(d)(1)(c)

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101212(d)(1)(c)Events reported shall include the following: (C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
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Director will provide a written plan to LPA on how she will ensure that any type of injury is reported to parent(s) and Department of Social Services via email by the POC date of 06/16/2023.
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This requirement was not met as evidenced by: LPAs was informed by director that an incident was not report to child's parent(s) and Department of Social Services, which is an immediate health, safety, and personal rights risk to children in care.
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LPA discussed LIC 624 and reporting with the Director. Director will email LPA at
Lorraine.Dacanay-Breaux@dss.ca.gov the written plan.
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: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023


LIC809 (FAS) - (06/04)
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