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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408757
Report Date: 05/26/2023
Date Signed: 05/26/2023 04:13:37 PM

Document Has Been Signed on 05/26/2023 04:13 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: 85TOTAL ENROLLED CHILDREN: 88CENSUS: 44DATE:
05/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Georgia RobelloTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janette Cruz, met with Georgia Robello, preschool Director, for an unannounced case management inspection in response to a self-reported Unusual Incident that the Facility reported to the Department. LPA observed that the teacher/child ratio was in compliance during today's inspection.

Per Unusual Incident Report submitted by Infant Director, Audry Carbajal, incident occurred on 05/12/2023 when infant child (C1) was reported to have sustained a burn on her left forearm. The burn was discovered by C1's parent after being picked-up from the day-care on 05/12/2023.

Georgia stated that she was not present during that morning of the incident reported on 3/31/2023. Georgia stated that there were three staff (one teacher and two teacher aids), supervising C1's classroom (room 2) on that day.

LPA also conducted staff interviews who were present during the incident. LPA reviewed the staff and child (C1's) records on facility file.
Based on the available information, Further investigation is required and shall be continued on a later date.

Exit interview was conducted with Georgia Robello, preschool director. A deficiency was cited during today's inspection, appeal rights were given.

A Notice of Site Visit was issued and must be posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
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 05/26/2023 04:13 PM - It Cannot Be Edited


Created By: Janette Cruz On 05/26/2023 at 11:50 AM
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: 05/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2023
Section Cited
CCR
101415.1(a)

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101415.1 Assistant Infant Care Center Director Qualifications and Duties
(a) In addition to the director, an assistant director shall be present and on duty if the center has 25 or more infants in attendance. This requirement was not met as evidenced by:
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Licensee will submit to the Department an application for Assistant Infant Care Center Director by POC due date. Licensee will submit a statement of understanding of licensing regulations for Assistant Infant Director requirement.
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Based on observation, interview and record review, Licensee did not comply with section cited above. Licensee did not have a qualified Assistant Infant Care Center Director for 44 children present upon inspection which posed a potential health, safety or
personal rights risk to persons 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: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023


LIC809 (FAS) - (06/04)
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