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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408755
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:55:00 PM

Document Has Been Signed on 10/05/2023 03:55 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: 254CENSUS: 99DATE:
10/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Georgia Andresen RobelloTIME COMPLETED:
10:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management-Other inspection. LPA met with Director Georgia Andresen Robello and explained the reason for the inspection.

At 9:55AM, LPA observed that there was one staff with seven children in K-3. The staff was with two children in the restroom. The other children were playing at the table or on the carpet. There are windows that look into the room; however, staff cannot visually see children.

As a result of this inspection, a Type B citation was issued. Exit interview conducted and report was reviewed with Director Georgia Andresen Robello. A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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 10/05/2023 03:55 PM - It Cannot Be Edited


Created By: Samantha Yip On 10/05/2023 at 01:41 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: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2023
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision. No child(ren) shall be left without the supervision of a teacher at any time,.... Supervision shall include visual observation.
This requirement is not met as evidenced by:
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By 10/12/2023, Director stated that she will submit a written plan on how she will ensure that children are supervised at all times.
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Based on observation, LPA observed at 9:51AM that there was one staff in the restroom with children. There were additional children outside, which staff cannot visual observe. This poses a potential health and safety 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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


LIC809 (FAS) - (06/04)
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