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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430709377
Report Date: 03/08/2023
Date Signed: 03/08/2023 10:20:32 AM


Document Has Been Signed on 03/08/2023 10:20 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:PRIMARY PLUSFACILITY NUMBER:
430709377
ADMINISTRATOR:GUZMAN, SHUREEFACILITY TYPE:
850
ADDRESS:18720 BUCKNALL ROADTELEPHONE:
(408) 370-0357
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY:278CENSUS: 135DATE:
03/08/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Shuree GuzmanTIME COMPLETED:
10:30 AM
NARRATIVE
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On 03/08/2023, Licensing Program Analyst (LPA) Pete Hernandez, met with Director, Shuree Guzman, for a case management visit in regards to the lead testing results submitted by the facility and explained the reason for the visit to them. Present were 19 staff with 135 children in care.

Facility submitted that there is an exceedance of about 11 (ppb) sample (D) room K3 from the sink faucet and 5.8 (ppb) sample (P) room 7 sink faucet. Director stated that all the above have been disabled and repairs are expected in two weeks once ordered parts are received. Retesting will be scheduled once repairs are completed. They are expected to be completed by mid-April 2023. The facility uses water for the staff and children from other faucets that have passed lead safety testing of 5.5 (ppb) or less.

Type B deficiency was cited during today's visit. Director was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made. Exit interview conducted and report was reviewed with the Director, Shuree Guzman,

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
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 03/08/2023 10:20 AM - 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: PRIMARY PLUS
FACILITY NUMBER: 430709377

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2023
Section Cited

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101700.3(b)(1)
Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level. A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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By the POC date: Facility will provide proof of repairs and retest results by 5/01/2023. Identified fixtures are not to be used until cleared for use after retesting.
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Facility submitted that there is an exceedance of about 11 (ppb) sample (D) room K3 from the sink faucet and 5.8 (ppb) sample (P) room 7 sink faucet.
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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: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
LIC809 (FAS) - (06/04)
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