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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430709448
Report Date: 05/10/2023
Date Signed: 05/10/2023 10:37:25 AM


Document Has Been Signed on 05/10/2023 10:37 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 PLUS - INFANTSFACILITY NUMBER:
430709448
ADMINISTRATOR:LOPEZ, LORENAFACILITY TYPE:
830
ADDRESS:18720 BUCKNALL ROADTELEPHONE:
(408) 370-0350
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY:83CENSUS: 47DATE:
05/10/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Lorena LopezTIME COMPLETED:
10:15 AM
NARRATIVE
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On 03/08/2023, Licensing Program Analyst (LPA) Pete Hernandez, met with Director, Lorena Lopez, 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 16 staff with 47 children in care.

Facility submitted that there is an exceedance of about 16 (ppb) sample (F) room K5 from the sink faucet and 5.6 (ppb) sample (F30). Director stated that the above have been disabled and repairs are now completed. No retesting will be scheduled Because the sink was completely removed from service. 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 and cleared 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, Lorena Lopez,

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: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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 05/10/2023 10:37 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 - INFANTS
FACILITY NUMBER: 430709448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2023
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. This requirement is not met as evidenced by:
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By the POC date: Facility will provide proof of repairs and retest results by 5/017/2023 to CCLD. Identified fixture is not to be used until cleared for use after retesting.
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Facility submitted that there is an exceedance of about 16 (ppb) sample (F) room K5 from the sink faucet and 5.6 (ppb) sample (F30).
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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: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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