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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408757
Report Date: 12/14/2021
Date Signed: 12/15/2021 08:15:26 AM

Document Has Been Signed on 12/15/2021 08:15 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:
434408757
ADMINISTRATOR:SARAH VAZQUEZFACILITY TYPE:
830
ADDRESS:5845 ALLEN AVENUETELEPHONE:
(408) 629-6020
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 88TOTAL ENROLLED CHILDREN: 88CENSUS: 32DATE:
12/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:31 PM
MET WITH:Audry Carbajal and Georgia AndresenTIME COMPLETED:
07:15 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 32 children and at least 8 staff. The teacher-child ratio was observed to in compliance during today's inspection.

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 1, 2, , 7, and 8. Disinfectants, cleaning supplies, and other items that could pose a risk to children were observed to be inaccessible to children. LPA observed that there was a bottle of cleaning solution under the sink and ant spray. Director moved cleaning solution to upper shelf in the closet and ant spray where it was out of reach of children. All toys and equipment were observed to be age appropriate and in good condition. LPA observed that in Room 1 that sleeping area is not separate from the activity area. There is a shelf that is about 1 feet, but infants still have access to cribs. Director stated that they will install a half way and send proof to Licensing. LPA reminded Director that all sheets on the crib need to be tight fitted. 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.

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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.

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: 434408757
VISIT DATE: 12/14/2021
NARRATIVE
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The outside area is fenced. There were no bodies of water of observed during today's inspection. Shaded rest area is provided through pergola.

LPA discussed the safe sleep regulations with Director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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



All meals and snacks are prepared and brought from home. LPA reminded Director that all food brought from home needs to have the child's name and date on it. Drinking water is provided through individual sippy cups.

8 children's files were reviewed during today's inspection. The records reviewed include but not limited to Individual Sleep Plan, Needs and Service Plan, and notification of parent's rights.
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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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Document Has Been Signed on 12/15/2021 08:15 AM - It Cannot Be Edited


Created By: Samantha Yip On 12/14/2021 at 06:03 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: 434408757

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. Faciltiy does not have a carbon monoxide detector, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2021
Plan of Correction
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By POC 12/27/2021, Director stated that she will submit proof of carbon monoxide detector.
Type B
Section Cited
CCR
101419.3(a)
Modifications to Infant Needs and Services Plan
(a) The written infant needs and services plan shall be updated at least quarterly, or as often as necessary to assure its accuracy.

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. LPA observed that C-1 and C-2 did not have updated Needs and Service Plan, which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2021
Plan of Correction
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By POC 12/27/2021, Director stated that she will send updated Needs and Service plan to Licensing.
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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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: 434408757
VISIT DATE: 12/14/2021
NARRATIVE
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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.

As a result of this inspection, 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.

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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