<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430709377
Report Date: 11/05/2019
Date Signed: 11/05/2019 10:15:05 PM



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
08/07/2019 and conducted by Evaluator Elizabeth Berumen
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20190807085052
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: 173DATE:
11/05/2019
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Melissa ChapaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Child sustained a serious bite mark while in care un-witnessed by staff

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Elizabeth Berumen conducted an unannounced complaint inspection to deliver findings. LPA met with Director, Melissa Chapa to explain the nature of today's inspection.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

NOTICE OF SITE VISIT WAS ISSUED AND SHALL REMAIN POSTED FOR 30 DAYS.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2019
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 1