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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408757
Report Date: 07/19/2022
Date Signed: 07/19/2022 03:30:19 PM

Document Has Been Signed on 07/19/2022 03:30 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:
434408757
ADMINISTRATOR:AUDRY CARBAJALFACILITY TYPE:
830
ADDRESS:5845 ALLEN AVENUETELEPHONE:
(408) 629-6020
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 88TOTAL ENROLLED CHILDREN: 88CENSUS: 39DATE:
07/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Georgia AndersenTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Samantha Yip and Janette Cruz conducted an unannounced Case Management- Other. LPA met with Assistant Director Georgia Andersen and explained the reason for the inspection. The purpose of this inspection is facility separated the sleeping area from the indoor activity area in Room 1. LPA observed during Required 1 Year inspection on 12/14/2021 that the sleeping area was not physically separated from the indoor activity area. A updated fire clearance was granted on 06/27/2022. Present during today's inspection were 38 children and 10 staff. Facility is licensed to serve children ages birth to 2 years old in Room 1, 2, 7, 8, and 13. Assistant Director stated that they are currently not using Room 13. Their capacity is for 88.

LPAs inspected the rooms. LPAs observed that the facility is using shelves with plexi-glass attached to the top to separate the sleeping area from the indoor activity area, which is at least 4 feet high. There is a retractable gate to go from the napping area and the activity area. There were four cribs in the napping area. Indoor measurements were conducted during today's inspection. The measurements are as followed:

Room 1
18.917 x 14.500 = 274.296 + 10.583 x 9.750 = 103.184 = 274.296 + 103.184 = 377.48

Room 2
27.333 x 18.583 = 507.929 + 11.333 x 20.417 = 231.385 = 507.929 + 231.385 = 739.314 minus encumbered space 3.250 x 1.917 = 6.230 + 1.667 x 2.083 = 3.472 + 3.583 x 3.250 = 11.644 = 21.346 = 739.314 - 21.346 = 717.968

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
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: 07/19/2022
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----------------------continuation of 809 dated 07/19/2022 page 1-----------------------------------

Room 7
29.583 x 9.750 = 288.434 + 5.583 x 12.750 = 71.183 + 3.500 x 8.583 = 30.040 = 389.657

Room 8
20.667 x 29.417 = 607.961 + 18.500 x 6.250 = 115.625 + 2.500 x 8.583 = 21.45 = 745.043 minus encumbered space 2.083 x 1.667 = 3.47 + 1.833 x 3.167 = 5.805 + 3.668 x 3= 11.001 = 20.276 = 745.043 - 20.276 = 724.767

Room 13
39.333 x 23.23.250 = 914.492 minus encumbered space 2.417x 2.083 =5.034 + 14 x 2.333 = 32.662 + 5.333 x 2.333 = 12.441 + 4.917 x 2= 9.834 + 1.583 x 2= 3.166 = 126.274 = 914.492-126.274 = 788.218

Total Indoor Square Footage: 377.48 + 717.968 + 389.657 + 724.767 + 788.218 = 2998.09 divided by 35 = 85 children

Due to indoor measurements measuring for 85 children, facility will need to submit for a change of capacity.

There were at least 61 cots, 84 chairs, 11 tables, 74 cubbies, 16 cribs, and at least 6 sinks. Changing table was within reach of a sink. Facility uses baskets for children's belongings. Facility understands that there needs to be at least one basket for each child. There are toys and equipment for children, which were age appropriate. Food is prepared and brought from home. There is a refrigerator in each class to store food. Drinking water is provided through individual sippy cups and water bottles. Trash cans have tight-fitted lids.

----------------------continues on 809 dated 07/19/2022 page 3-----------------------------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
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: 07/19/2022
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----------------------continuation of 809 dated 07/19/2022 page 2--------------------------------

LPA observed that one child was sleeping in the crib and had a lovey inside. There were two children who were trying to go down for a nap in the crib who had pacifiers. One of the child had a pacifier that had a leash attached to it and the other had a stuff animal attached. Staff removed the lovelies and pacifiers during inspection. There was also one child who was going down for a nap in the crib who had a bib inside the crib. LPA also observed that one of the cribs had two mattress covering the side of the crib. LPA discussed with Assistant Director that staff can see children in the crib and there cannot be anything in the crib. LPA also discussed with Assistant Director that there cannot be anything attached to pacifiers. LPA discussed the safe sleep regulations with Assistant Director and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Assistant Director 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.

Facility will submit the following:
- LIC 200A to reflect the changes to capacity
- updated LIC 999: Facility Sketch

As a result of this inspection, an Type B citation was issued. Exit interview conducted and report was reviewed with Assistant Director, Georgia Andersen. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/19/2022 03:30 PM - It Cannot Be Edited


Created By: Samantha Yip On 07/19/2022 at 12:14 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: 07/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2022
Section Cited
CCR
101439.1(f)

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Infant Care Center Sleeping Equipment. Cribs shall be free from all loose articles and objects, including blankets and pillows.
This requirement is not met as evident by:
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Staff removed lovey from the crib during inspection.
Assistant Director stated that she will conduct training with staff regarding safe sleep and send proof of staff who attended training to Licensing.
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Based on observation, LPA observed that there was child with a lovey in the crib, which 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: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022


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