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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408757
Report Date: 01/24/2024
Date Signed: 01/24/2024 02:46:34 PM

Document Has Been Signed on 01/24/2024 02:46 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: 79CENSUS: 56DATE:
01/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Audry CarbajalTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janette Cruz , met with facility
Director, Audry Carbajal, for an unannounced case management inspection in response to a self-reported Unusual Incident that was reported to the Department on 12/19/23.

On 12/19/2023, Director reported and provided LPA with an unusual incident report stating that on 11/29/23, a teacher aide (T1) and a parent witnessed an infant (C1) was grabbed by the arms to forcibly lay her down on the mat to sleep and was also pat roughly by another teacher aide (T2).

LPA conducted staff and parent interviews pertinent to this case management inspection. LPA also reviewed child's records on facility file. Based on the available information, deficiencies are being cited, see 809-D. Appeal rights were given.
Exit interview was conducted and reviewed with Audry Carbajal, Director.

Notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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 01/24/2024 02:46 PM - It Cannot Be Edited


Created By: Janette Cruz On 01/24/2024 at 01:25 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: 01/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
101212(d)(1)(c)

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101212 Reporting Requirements
(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
(1) Events reported shall include the following:
(C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child. This requirement was not met as evidenced by:
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Licensee submitted the Unusual Incident Report on 12/19/2023. Licensee submitted a statement of understanding of reporting requirements per regulations. Deficiency cleared.
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Based on observation, interviews and record reviews, Licensee did not comply with section cited above. Licensee submitted an unusual incident report on 12/19/23 of an incident that happened on 11/29/23 which poses a potential threat to health and safety of 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:Diana Stephenson
LICENSING EVALUATOR NAME:Janette Cruz
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/24/2024 02:46 PM - It Cannot Be Edited


Created By: Janette Cruz On 01/24/2024 at 02:07 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: 01/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/25/2024
Section Cited
CCR
101223(a)(3)

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101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not met as evidenced by:
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Licensee immediately dismissed staff who was involved in the incident of violation of child's personal rights. Proof of staff termination submitted.
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Based on observation, interviews and record reviews, Licensee did not comply with section cited above: Child, C1 was grabbed by the arms to forcibly lay her down on the mat to sleep and was also pat roughly by a staff. This poses an immediate threat to health and safety of children 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: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
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