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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434415175
Report Date: 04/03/2024
Date Signed: 04/03/2024 03:16:09 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 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
03/19/2024 and conducted by Evaluator Jessica Bongardt
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20240319101054
FACILITY NAME:ACTION DAY PRIMARY PLUSFACILITY NUMBER:
434415175
ADMINISTRATOR:BATE, STEPHANIEFACILITY TYPE:
830
ADDRESS:2164 LINCOLN AVENUETELEPHONE:
(408) 266-8188
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:18CENSUS: 16DATE:
04/03/2024
UNANNOUNCEDTIME BEGAN:
02:24 PM
MET WITH:Lucy NunezTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Licensee did not notify parents/guardians of Type A citation in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Bongardt conducted a subsequent complaint visit and met with Lucy Nunez, Site Director today. The purpose of LPA’s visit was to deliver investigation findings.

On March 22, 2024, and April 03, 2024, LPA conducted unannounced inspections of the facility. During the course of the investigation, staff and parent interviews were conducted. Facility records were reviewed.

Reporting Party (RP) stated that they did not receive the notification of a Type A citation upon the enrollment of the child into the facility. LPA did record reviews and saw that children that were placed in care during the time of the citation, also did not have the notification of receipt of the Type A citation (LIC 9224) that was given.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
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-20240319101054
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 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: 04/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2024
Section Cited
HSC
1596.8595(c)(1)(2)
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(1) A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights...(2) Upon enrollment of a new child in a facility, the licensee shall provide to the parents or legal guardians of the newly enrolling child copies of any licensing report that the licensee has received during the prior 12-month period that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care...
This requirement was not met as evidence by:
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Licensee will have all parents sign a sheet stating they received the Type A citation and that sign-in sheet will be sent to the department by the plan of correction date.
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Based on observation and record review the licensee did not comply with the section cited above by not having all parents sign the LIC 9224 when the Type A citation happened (OCT 2023) and when they have newly enrolled students into this facility which poses 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.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 07-CC-20240319101054
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 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: 04/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2024
Section Cited
HSC
1596.8595(c)(3)(4)
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(3) The licensee shall require each recipient of the licensing report described in paragraph (1) pertaining to a complaint investigation to sign a statement indicating that he or she has received the document and the date it was received.
(4) The licensee shall keep verification of receipt in each child's file.
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Licensee will have all parents sign the LIC 9224 and submit proof to the department by the proof of correction date.
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Based on observation and record review the licensee did not comply with the section cited above by not having all parents sign the LIC 9224 when the Type A citation happened (OCT 2023) and when they have newly enrolled students into this facility which poses 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.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 07-CC-20240319101054
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ACTION DAY PRIMARY PLUS
FACILITY NUMBER: 434415175
VISIT DATE: 04/03/2024
NARRATIVE
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Based on investigation, file review, and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

A notice of site visit will be issued and must be posted for 30-days.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4