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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430709377
Report Date: 06/07/2019
Date Signed: 06/07/2019 09:17:37 AM



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
03/19/2019 and conducted by Evaluator Stephanie C Rangel
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20190319170517
FACILITY NAME:PRIMARY PLUSFACILITY NUMBER:
430709377
ADMINISTRATOR:CHAPA, MELISSAFACILITY TYPE:
850
ADDRESS:18720 BUCKNALL ROADTELEPHONE:
(408) 370-0357
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY:278CENSUS: 152DATE:
06/07/2019
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Melissa ChapaTIME COMPLETED:
09:25 AM
ALLEGATION(S):
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Preschool has a shortage of bathroom supplies for more than a few days.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Rangel, met with Director, Melissa Chapa, to deliver findings on the above allegation. During the course of the investigation, LPA interviewed staff and children. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division& Chapter number), are being cited on the attached LIC 9099D.”).

Deficiency is cited on the following page. Appeal rights printed and reviewed.

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 07-CC-20190319170517
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: PRIMARY PLUS
FACILITY NUMBER: 430709377
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2019
Section Cited
CCR
101239(g)
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The licensee shall provide linens of various kinds as necessary to meet the program of services offered by the center and the requirements specified in this chapter. This requirement was not met as evidenced through interviews that at times, there was not enough paper towels at the center. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Director has planned to ensure that the facility will remain stocked with bathroom supplies. Written plan of correction to be sent to CCL by POC due date of 6/14/19.
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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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2019
LIC9099 (FAS) - (06/04)
Page: 2 of 2