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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430701361
Report Date: 04/04/2023
Date Signed: 04/04/2023 04:14:36 PM


Document Has Been Signed on 04/04/2023 04:14 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:ACTION DAY NURSERYFACILITY NUMBER:
430701361
ADMINISTRATOR:JILL MILLERFACILITY TYPE:
850
ADDRESS:2146 LINCOLN AVENUETELEPHONE:
(408) 266-8952
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:154CENSUS: 148DATE:
04/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:28 PM
MET WITH:Jamie FergusonTIME COMPLETED:
04:30 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Kassandra Medrano conducted a Case Management inspection today. LPA met with Jamie Ferguson, Regional Director and Brittany Bostic, Site Director the purpose of the visit was explained. During tour of the facility with both directors, at 2:54pm it was observed that cabinet underneath the sink in classroom 9B was left open. Upon inspection of cabinet it was found that facility did not ensure cleaning products were made inaccessible. It was observed that both locks on the cabinet door were broken. In the cabinet under sink LPA found 2 bottles of bleach, one can of sink cleaner, and a bottle of Windex. Staff immediately removed said poisons from unlocked cabinet.

Exit interview conducted and report was reviewed with the facility representative, Jamie Ferguson.

California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):

"NOTICE OF SITE VISIT" DOCUMENT WAS POSTED ADJACENT TO THE MAIN ENTRY DOORWAY AND VISIBLE TO PARENTS. LICENSEE MUST POST ANY TYPE A DEFICIENCIES DURING TODAYS VISIT WITH THE NOTICE AND LICENSEE UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR AB 633 FACT SHEET AND A COPY OF ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH APPLICANT/PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra MedranoTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
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 04/04/2023 04:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: ACTION DAY NURSERY
FACILITY NUMBER: 430701361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2023
Section Cited

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101238 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.(1) Storage areas for poisons shall be locked.
The requirement was not meant as evidenced by:
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Cleaning products were removed, director to send proof of lock being fixed.
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During tour of facility at 2:54 it was observed in classroom 9B that facility did not ensure that cleaning products were locked and made inaccesible to children. This posed an immediate risk 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.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra MedranoTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
LIC809 (FAS) - (06/04)
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