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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434415175
Report Date: 04/20/2021
Date Signed: 04/22/2021 09:39:00 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2021 and conducted by Evaluator Deanna Villagrana
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20210202145153
FACILITY NAME:ACTION DAY PRIMARY PLUSFACILITY NUMBER:
434415175
ADMINISTRATOR:PAULA SCHROEDERFACILITY TYPE:
830
ADDRESS:2164 LINCOLN AVENUETELEPHONE:
(408) 266-8188
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:18CENSUS: 10DATE:
04/20/2021
UNANNOUNCEDTIME BEGAN:
02:54 PM
MET WITH:Jill MillerTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility is out of ratio
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs), Deanna Villagrana and Ofelia Calivo, conducted a televisit via Facetime with Acting Director Jill Miller to deliver findings for the above allegation. LPAs explained the nature of the televisit to her. LPAs observed one aide with four infants in the napping room and two teachers with five infants in the play room. LPAs observed water was working at both diaper area stations.

LPAs conducted interviews and obtained pertinent documents. Based on time sheets, teacher qualifications and sign in/out sheets for children, the facility was out of ratio. It was noted that Hutaf Kafeety and Shyla Duarte are not qualified infant teachers as they have not completed three semester unit in the care of infants and were left alone with four infants on 02/16/2021 and one infant on 02/17/2021 during the morning hours. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. The following type B deficiency was cited on the attached page (809-D). Director was informed that failure to correct the deficiency by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

Notice of site visit was issued and must be posted for 30 days.

This report has been emailed to Director and Director will reply to email in lieu of a signature.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 07-CC-20210202145153
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 434415175
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2021
Section Cited
CCR
101416.5(b)
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101416.5(b) There shall be a ratio of one teacher for every four infants in attendance. This requirement was not met as evidenced by: Based on time sheets, teacher qualifications and sign in/out sheets for children, the facility was out of ratio. It was noted that Hutaf Kafeety and Shyla Duarte are not qualified infant teachers as
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Director Jill Miller will send and updated schedule showing a qualified opening and closing infant teacher. Included it will state who will be a qualified infant backup teacher for breaks and lunches. Director will email LPA not later than 04/22/2021.
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they have not completed three semester unit in the care of infants and were left alone with four infants on 02/16/2021 and one infant on 02/17/2021 during the morning hours. This poses an immediate risk to the Health, Safety or Personal Rights 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.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2021 and conducted by Evaluator Deanna Villagrana
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20210202145153

FACILITY NAME:ACTION DAY PRIMARY PLUSFACILITY NUMBER:
434415175
ADMINISTRATOR:PAULA SCHROEDERFACILITY TYPE:
830
ADDRESS:2164 LINCOLN AVENUETELEPHONE:
(408) 266-8188
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:18CENSUS: 10DATE:
04/20/2021
UNANNOUNCEDTIME BEGAN:
02:54 PM
MET WITH:Jill MillerTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Staff left day care children unattended
Infants heads are covered with blankets while napping
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs), Deanna Villagrana and Ofelia Calivo, conducted a televisit via Facetime with Acting Director Jill Miller to deliver findings for the above allegation. LPAs explained the nature of the televisit to her. LPAs observed one aide with four infants in the napping room and two teachers with five infants in the play room.

LPAs conducted interviews with staff and obtained pertinent documents. Based on LPA's observation, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Notice of site visit was issued and must be posted for 30 days.

This report has been emailed to Director and Director will reply to email in lieu of a signature.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4