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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408755
Report Date: 03/08/2023
Date Signed: 03/08/2023 04:09:58 PM

Document Has Been Signed on 03/08/2023 04:09 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: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: 167CENSUS: 153DATE:
03/08/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Audry Carbajal TIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janette Cruz, conducted an unannounced case management inspection and met with Audry Carbajal, Infant Director. LPA explained the purpose of today’s inspection is to follow-up lead testing completed on 12/17/22 that indicated water outlets found to have Action Level Exceedance (ALE) on the following water outlets and locations:
Outlet M - 8.2 ppb - Room K4
Outlet E - 8.2 ppb - Room K1
Outlet N - 5.7 ppb - Room K5
Outlet L - 14 ppb - Room K4

LPA informed Director that results of water testing indicated ALE, hence, water from these outlets are deemed not safe to drink or be used for food preparation due to elevated levels of lead.

Census was taken, a total of 153 children were present with 16 staff supervising. LPA reviewed the water sample summary and requested Director to identify water outlets “M, E, N and L."

LPA observed that plastic bags are placed over the affected water faucets making them inaccessible for use. Director stated that the remediation process on all outlets had started and professional plumbing is scheduled tomorrow 3/9/23 to replace all faucets marked unsafe for drinking or use. Director stated that there is no water re-sampling scheduled at this time. Director stated that the facility provides water to children via water jugs collected from safe water outlets (ex. cafeteria) or children bring their own water from home. Director stated that they currently do not have bottle waters readily available for consumption on site. Director stated that the facility provides meals for the children and water being used for food preparation comes from the water faucet located in their cafeteria.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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 03/08/2023 04:09 PM - It Cannot Be Edited


Created By: Janette Cruz On 03/08/2023 at 02:04 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: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2023
Section Cited

101700.3(b)(1)

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101700.3(b)(1)Lead Testing Written Directives a result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
This requirement was not met as evidenced by
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Licensee will submit a written plan of action by POC date 3/22/23 stating the affected water outlets will be repaired, submit proof of plumbing/repair and water retested within 30 days before use for drinking. Licensee will have bottled waters available on site.
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Based on on observation and record reviews, water sampling report for the facility indicated that water from four outlet sites have elevated lead greater than 5.5ppb which poses a potential health and safety or personal risk to children in care.
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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:Diana Stephenson
LICENSING EVALUATOR NAME:Janette Cruz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023


LIC809 (FAS) - (06/04)
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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: 03/08/2023
NARRATIVE
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 LPA obtained the following facility documents during todays inspection: Self-Certification (LIC9275) completed by Certified External Water Sampler, Sampling Checklist Form (LIC9276), Facility Sketch (LIC999) labeled with locations of water outlets that were tested and water testing summary conducted by Enthalpy Analytical on 12/17/22.

As a result of this inspection, Type B deficiency was cited on the following page.
Exit interview conducted and report was reviewed with Director, Audry Carbajal.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC809 (FAS) - (06/04)
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