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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430709448
Report Date: 06/07/2023
Date Signed: 06/07/2023 01:17:56 PM


Document Has Been Signed on 06/07/2023 01:17 PM - 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: 41DATE:
06/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Lorena LopezTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pietro Hernandez and conducted an unannounced case management - other inspection today. LPA met with Director Lorena Lopez and explained to her the purpose of the inspection.

During the course of the complaint investigation dated 5/16/22023, LPA reviewed files and documentation and observed that sign in and sign out records for C1 and C2 were not signed in as attended on 3/29/2022, 4/4/2022, 4/12/2022, 5/2/2023, 5/23/2022, and 6/27/22. The LPA had received copies of "ouch reports" that were completed and signed on the dates above. The facility did not have records that reflected that these infants were signed in or out on the dates listed above.

A deficiency is being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, and Plan of Corrections were reviewed and developed with the licensee. A copy of this report and appeals rights were discussed and left with the Licensee, Lorena Lopez, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
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 06/07/2023 01:17 PM - 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: 06/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2023
Section Cited
CCR
101229.1(b)

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101229.1 (b) SIGN IN AND OUT. The person who brings the child to, and removes the child from, the center shall sign the child in/out.
This requirement is not met as evidenced by:
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BY POC DUE DATE, Director will send to Licensing Office a plan of action on how facility will ensure that parents are signing their children in and out.
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Facility is using an electronic system for parents to sign their child in and out of the school. Per LPAs' review of the
electronic log-ins records from 3/1/2022 through 6/30/2022, C1 and C2 were were not signed in as attended on 3/29/2022, 4/4/2022, 4/12/2022, 5/2/2023, 5/23/2022, and 6/27/22. Other records show they attended these days.This poses a potential risk to the health and safety of children in care.
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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: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
LIC809 (FAS) - (06/04)
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