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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417100
Report Date: 11/20/2024
Date Signed: 11/20/2024 10:58:38 AM

Document Has Been Signed on 11/20/2024 10:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 NURSERIES & PRIMARY PLUS INCFACILITY NUMBER:
434417100
ADMINISTRATOR/
DIRECTOR:		JAMIE FERGUSONFACILITY TYPE:
850
ADDRESS:2021 LINCOLN AVENUETELEPHONE:
(408) 244-1968
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 25TOTAL ENROLLED CHILDREN: 25CENSUS: 9DATE:
11/20/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Jamie FergusonTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jennifer "Jen" Beehler met with Site Director, Jamie Ferguson for an unannounced lead exceedance inspection. LPA was greeted at the door by a teacher and lead to the back of the facility where Director Smriti Datta was available, who is the Site Director for facility #430701361. Smriti stated she would call Jamie to attend the inspection. The Director, Jamie Ferguson and the Assistant Director for the site, Susan Lee arrived shortly.

LPA conducted an investigation of the facility grounds. LPA was directed to the location of the water fixture. LPA observed no plumbing. The pipes had been removed and all that remained was a fence and the cement slab below. LPA disclosed to the Directors that on 11/07/2024 a lead exceedance test was uploaded to an internal site that tracks lead exceedance testing for licensed facilities. This test was completed on 11/28/2023, but the department had not been notified of the results. LPA reminded Directors of the following directives that are outlined in the PIN 21-21.1-CCP:

Immediately cease using the fixture, notify parents of the lead exceedance results and create a plan of correction for the fixture. Within two weeks after a completed sampling, providers must submit to the licensing Department the LIC9275 and the LIC9276 along with the LIC999 Facility sketch identifying the location of the fixtures and any related documents which could include a copy of the lead testing report, photos of outlets, work order or proof of correction, or a plan to correct.

On 11/29/2023, licensee failed to maintain a lead value at or below the Action Level for water lead testing resulting with values of 5.5 ppb or greater for the playground water fountain. Water testing results identified with Action Level Exceedance as defined in WD section 101700.3 are not deemed safe to drink, The facility failed to notify licensing of the exceedance result, provide any documentation, plan of correction or proof of correction within the allotted two week timeline.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 NURSERIES & PRIMARY PLUS INC
FACILITY NUMBER: 434417100
VISIT DATE: 11/20/2024
NARRATIVE
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Regional Director Brittany Strange provided a copy of the report and a receipt from the plumber showing the water fixture with lead exceedance was removed on 12/08/2023 which was 9 days after the report was released which is in compliance to the two week timeline outlined in the written directives.

Directors stated that the water fixture was never used since they purchased the facility. Licensee turned the fixture on to test and immediately turned it off because they believed that is what they were required to do. When the test results showed the exceedance of lead levels they put a plastic bag over the fixture with a note to communicate it was never to be turned on.

LPA asked if parents had been notified of the report. Staff stated they did not know. LPA reminded Director's during inspection, that all facilities should have completed these steps last year. If their leadership team is unsure if every facility has complied, they should review the files and reach out to the Department in accordance with written directives.

Due to today's inspection a Type B deficiency was cited, more details are provided in the LIC809-D. Exit interview conducted with Assistant Director Susan Lee, report reviewed and provided along with appeals rights.

NOTICE OF SITE VISIT WAS PROVIDED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2024 10:58 AM - It Cannot Be Edited


Created By: Jennifer Beehler On 11/20/2024 at 10:10 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 NURSERIES & PRIMARY PLUS INC
FACILITY NUMBER: 434417100

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2024
Section Cited
HSC
1597.16(a)(1-3)

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....(i) Notify the department if there is a change to the recommended action level for lead in water.

This requirement has not been met as evidenced by:
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Licensee has corrected the affected fixture by removing it on 12/08/2023. Licensee will provide the proper documentation for the Action Lead Exceedance directives to the Department by 12/02/2024.
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Licensee failed to notify the department of the lead exceedance results within two weeks of the report received.
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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:Joel Segura
LICENSING EVALUATOR NAME:Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
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