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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408757
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:32:09 PM

Document Has Been Signed on 09/14/2023 03:32 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: 86CENSUS: 61DATE:
09/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Audry CarbajalTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Janette Cruz and Jessica Bongardt met with Audry Carbajal, Director, for an unannounced case management inspection in response to a self-reported unusual Incident that was reported to the Department. Today's visit is a follow-up to LPA Cruz' previous case management visit to the Facility on 05/26/23. LPA observed 61 children and 16 staff in the five classrooms open.

LPAs conducted additional interviews pertinent to this case management inspection. LPAs also reviewed staff and children's records on facility file.

Based on the available information, a day care child sustained burn injuries on her left forearm while at the daycare. A Type “A” deficiency regarding Responsibility for Providing Care and Supervision for Infants is being cited. See 809-D page. Appeal rights were issued.

Exit interview was conducted and report was reviewed with Audry Carbajal, Director
A notice of site visit and copy of today's report was given and must be posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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 09/14/2023 03:32 PM - It Cannot Be Edited


Created By: Janette Cruz On 09/14/2023 at 02:01 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: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2023
Section Cited
CCR
101429(a)(1)

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101429 Responsibility for Providing Care and Supervision for Infants
(a) In addition to Section 101229, the following shall apply:
(1) Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times. This requirement was not met as evidenced by:
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Licensee will submit to LPA Cruz a proof of in-service training conducted to staff regarding Responsibility for Providing Care and Supervision on Infants. Licensee will also submit to LPA a written plan of action indicating what steps will be implemented to ensure infants are supervised at all times to prevent injuries while under facility's care.
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Based on observation, interviews and record reviews, a day care child sustained burn injuries on her left forearm while at the daycare which posed an immediate health, safety or personal rights risk to persons in care.
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According to AB 633, parents must be provided with this report which contains this Type A deficiency for the next 12 months and copy of signed acknowledgement form must be kept in each child's file. According to AB 633, parents must be provided with this report which contains this Type A deficiency for the next 12 months and copy of signed acknowledgement form must be kept in each child's file.

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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: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023


LIC809 (FAS) - (06/04)
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