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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408757
Report Date: 01/12/2023
Date Signed: 01/12/2023 04:05:24 PM

Document Has Been Signed on 01/12/2023 04:05 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: 64CENSUS: 49DATE:
01/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Audry CarbajalTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPAs) Marilou Monico and Cynthia Tamayo conducted a Case Management Inspection to measure the outdoor space for the infant program.

The following measurements were taken today:
INFANT PLAYGROUND: 85.583 x 62.333 = 5,334.645 minus 286.506 (encumbered space) = 5,048.139
INFANT OUTDOOR SPACE TOTAL: 5,048.139 divided by 75 sq. ft. = 67 children

The playground is surrounded by appropriate fencing and the outdoor surfaces are safe. Shades are provided by pergolas, sails, tree, and building overhang. LPAs observed rubber foam as resilient material under the climbing structures. Drinking water outdoor is via water jug and disposable cups.

Exit interview conducted and report was reviewed with Site Director, Audry Carbajal. LPAs advised Audry that a license for 85 children in the infant program will be submitted to Licensing Management for the final stage of approval upon receiving the following items:

1) Waiver request to be licensed for 85 children in the infant program even though the playground is only measured for 67 children.

2) Fire clearance must be received.


SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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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