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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408755
Report Date: 12/14/2021
Date Signed: 12/15/2021 08:11:08 AM

Document Has Been Signed on 12/15/2021 08:11 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:ACTION DAY PRIMARY PLUSFACILITY NUMBER:
434408755
ADMINISTRATOR:RITIPAL(NEEKA)JUNEJAFACILITY TYPE:
850
ADDRESS:5845 ALLEN AVENUETELEPHONE:
(408) 629-6020
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 254TOTAL ENROLLED CHILDREN: 254CENSUS: 101DATE:
12/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Georgia Andresen and Audry CarbajalTIME COMPLETED:
03:30 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required 1 Year inspection. LPA met with Director Georgia Andresen and Audry Carbajal and explained the reason for the inspection. Present during the inspection were 101 children and 12 teachers. LPA observed that there were 18 children and 2 staff in Room 10. Neither staff were fully qualified.

There is board to post required postings, such as license and notification of parent's rights. There is working phone at the facility.

LPA toured in the inside and outside of the facility with Directors Georgia and Audry. Facility is currently only using Room K-1, K-2, K-3, K-4, K-5, Room 3, Room 4, Room 5, Room 10, and Room 11. Disinfectants, cleaning supplies, and other items that could pose a risk to children were observed to be inaccessible to children. LPA observed that in K- t3he floor in starting to warp by the children's table, which could become a tripping hazard. LPA also observed that the linoleum by the door of K-3's bathroom that was missing. Director stated they put a work order to fix the linoleum and the flooring. Director stated that she will send proof to Licensing once it is completed. There is a fully charged fire extinguisher and smoke detector. Facility does not have a carbon monoxide detector. Directors stated that they will send proof to Licensing. Directors stated that there are no weapons, such as firearms, stored on the premise.

The outside area is fenced. Area around play structure had resilient material. LPA observed that tan bark by the end of the slide was starting to get low. LPA discussed with Directors about racking tan bark so it is even. Director stated that they are currently replacing the

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ACTION DAY PRIMARY PLUS
FACILITY NUMBER: 434408755
VISIT DATE: 12/14/2021
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------------------------continuation of 809 dated 12/14/2021 page 1---------------------------------

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. LPA observed that 2 children were missing parent consent. Director stated that they will obtain written consent for parents and send proof to Licensing. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Facility only provides snacks to children. Menu was observed to be posted. All meals are either prepared and brought from home or brought through the hot meal program. Drinking water is provided through individual water bottles, water fountains, or water jug. Trash can for waste have a tight-fitted lid.

6 children's files were reviewed during today's inspection. The records reviewed include but not limited to emergency contact card.

Staff files were also reviewed during today's inspection. The records reviewed include but not limited to transcript, Mandated Reporter training, and immunization records. LPA observed that there were 2 staff who were missing immunization records for measles and pertussis, 1 staff who was missing immunization records for measles, and 2 staff who were missing immunization records for Tdap. LPA reminded Directors that all staff need to have immunization records on file. Director stated that she will submit proof to Licensing. LPA also observed that one staff was missing Health Screening and TB test. Director stated that she will send proof to Licensing. There is at least one staff on site with a valid CPR/1st Aid, which expires on 07/31/2023.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ACTION DAY PRIMARY PLUS
FACILITY NUMBER: 434408755
VISIT DATE: 12/14/2021
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Staff files were also reviewed during today's inspection. The records reviewed include but not limited to transcript, Mandated Reporter training, and immunization records. LPA observed that there were 2 staff who were missing immunization records for measles and pertussis, 1 staff who was missing immunization records for measles, and 2 staff who were missing immunization records for Tdap. LPA reminded Directors that all staff need to have immunization records on file. Director stated that she will submit proof to Licensing. LPA also observed that one staff was missing Health Screening and TB test. Director stated that she will send proof to Licensing. There is at least one staff on site with a valid CPR/1st Aid, which expires on 07/31/2023.

All staff present have cleared criminal record clearance, child abuse index, or exemption. Directors were reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA also discussed about AB 633 requirement to provided a copy of 809 report dated 12/142021 and obtain a signed copy LIC 9224 for each child in care within one business day. LPA also discussed with Directors Georgia and Audry that a copy of this report and a signed copy of LIC 9224 is required for any newly enrolled children within the 12 month period. LPA will email a copy of LIC 9224 and fact sheet to Directors Georgia and Audry.



As a result of this inspection, a Type A citation, Type B citations, technical violations, and technical assistances were issued. Exit interview conducted and report was reviewed with Director Georgia Andresen and Audry Pangilinan. A notice of site visit was given and must remain posted for 30 days; along with report.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/15/2021 08:11 AM - It Cannot Be Edited


Created By: Samantha Yip On 12/14/2021 at 06:17 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ACTION DAY PRIMARY PLUS
FACILITY NUMBER: 434408755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101216.3(b)(1)
Teacher-Child Ratio
(b) The licensee may use teacher aides in a teacher-child ratio of one teacher and one aide for every 15 children in attendance. (1) A ratio of one fully qualified teacher (as specified in Section 101216.1(c) and one aide for every 18 children in attendance in a preschool program is allowed when the aide meets the qualifications specified in Section 101216.2(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA observed that there were 2 staff with 18 children in Room 10. Neither of them are fully qualified, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2021
Plan of Correction
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Director stated that she will submit written plan on how she will ensure that there is at least one fully qualifed teacher at all time. Director will also submit a list of the teachers in the classroom.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2021


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Document Has Been Signed on 12/15/2021 08:11 AM - It Cannot Be Edited


Created By: Samantha Yip On 12/14/2021 at 06:17 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ACTION DAY PRIMARY PLUS
FACILITY NUMBER: 434408755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
HSC
1596.954
Licensure Requirements
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Facility does not have a carbon monoxide detector, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2021
Plan of Correction
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Director will send proof of carbon monoxide detector to Licensing.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in. 2 staff were missing Health Scrrening and TB, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2022
Plan of Correction
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By POC 01/31/2021, Director stated that she will send proof of S-1 and S-2's Health Screening and TB test.
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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/15/2021 08:11 AM - It Cannot Be Edited


Created By: Samantha Yip On 12/14/2021 at 06:17 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ACTION DAY PRIMARY PLUS
FACILITY NUMBER: 434408755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
101212(b)
Reporting Requirements
(b) The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. Director stated in 10/2021, but did not notify Licensing of the change. This posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 12/21/2021
Plan of Correction
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Deficiency was corrected.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2021


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