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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430709377
Report Date: 02/19/2020
Date Signed: 02/19/2020 12:48:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 PLUSFACILITY NUMBER:
430709377
ADMINISTRATOR:CHAPA, MELISSAFACILITY TYPE:
850
ADDRESS:18720 BUCKNALL ROADTELEPHONE:
(408) 370-0357
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY:278CENSUS: DATE:
02/19/2020
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Melissa ChapaTIME COMPLETED:
01:05 PM
NARRATIVE
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 Licensing Program Analyst (LPA), Behbood, conducted an unannounced visit to complete the annual required visit that initiated on 02/13/20. LPA met with Melissa Chapa, Site Supervisor. Purpose of the visit explained. On initial visit all 12 preschool classrooms and 3 playgrounds were inspected.
LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), Menus (includes current and following week), and Activity Schedule.
During today's visit LPA reviewed samples of children's and staff files. Parents sing in & out their children electronically. Each child's file reviewed contains the Identification and Emergency Information form (LIC 700) and a copy of the admission agreement. From the sample of staff file reviewed only 2 staff had current CPR and First Aid Certificate, which is not enough to comply with requirement that at least one person with current CPR & First Aid certificate must be present during operation hours (6:30 to 6:00) Melissa stated at least 5 staff have current CPR and First Aid but was unable to provide the certificates. Sample files reviewed had partial proof of immunization on file. Qualified staff have copies of their educational background on file. Staff have completed mandated Child Abuse Reporter Training some of training certificate will expire on 03/02/20 and Melissa was advised to ensure they will be renewed. Children bring lunch from home and some of them has the option of bringing AM and PM snacks even though facility provides 2 snacks daily. Menu was posted. Melissa is now aware that some of classrooms don't have the items listed on menu in the classroom, She agreed her staff will follow the menu and serve snacks from at least 2 food groups.

Report continues on next page.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/19/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2020
Section Cited

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Outdoor Activity Space - As a condition of licensure, the areas around and under high climbing equipment, swings, slides and other similar equipment shall be cushioned with material that absorbs falls. This requirement is
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not met evidence by: Tan barks on 2s playground is compacted and low. This is potentially harmful to health and safety of children,
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Type B
03/13/2020
Section Cited

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IMMUNIZATION SB792 - Staff must have proof of immunization against Measles and Pertussis on file. Flu can be optional if it is declined in writing. This requirement in not met evidence by: Staff #1 and 3 don't have proof
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of immunization against MeaslesStaff # 2 doesn't have any immunization records on file. This is potentially dangerous to health and safety of children.
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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: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 02/19/2020
NARRATIVE
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No bodies of water observed on the premises. Trash can for food waste has a tight fitting cover. Furniture & equipment appear in good condition. Floors appear clean. Children's bathrooms are in operating condition.
Playground has climbing structure, sand boxes, etc. are used for cushioning material.
Drinking water inside the classrooms and in the playground are provided via water containers. .
Please see next page for citation under Title 22.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2020
LIC809 (FAS) - (06/04)
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