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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430709448
Report Date: 11/06/2020
Date Signed: 11/06/2020 01:40:51 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 PLUS - INFANTSFACILITY NUMBER:
430709448
ADMINISTRATOR:LOPEZ, LORENAFACILITY TYPE:
830
ADDRESS:18720 BUCKNALL ROADTELEPHONE:
4083700350
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY:83CENSUS: 28DATE:
11/06/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Lorena LopezTIME COMPLETED:
02:18 PM
NARRATIVE
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On 10/20/2020 at 1:52pm: LPA Pete Hernandez contacted Director Lorena Lopez on her cell phone and initiated a FaceTime tele-inspection. Licensing Program Analysts (LPA), Pete Hernandez, made a case management inspection - incident in response to an unusual incident that was self-reported to Licensing by Director, Lorena Lopez, on October 15, 2020. During today's inspection, LPA toured the facility and interviewed staff, and parent of child in report. LPA learned that on October 15, 2020, an infant had wandered out of the entrance gate and into the parking lot. The staff members who were caring for the child were leaving the infant playground when the incident occurred and did not witness the child leaving the group. Due to Covid-19 the gates had been left open to reduce chance of pathogen transfer. The staff took a head count prior to leaving the infant playground and did not notice that the child was missing until they took a second headcount when they returned to the classroom. One of the teachers immediately left the classroom to find the child in the parking lot. Immediately following this incident, the Director wrote up plan of corrections that require all gates to be closed at all times.

TYPE A language: Due to the issuance of Type A citations today, a copy of the Facility Evaluation Report LIC809 dated 11/06/2020 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

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SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020
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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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 - INFANTS
FACILITY NUMBER: 430709448
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2020
Section Cited

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Care and Supervision for Infants 101429(a)(1). Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times. This requirement is not met as evidenced by:
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LPA's observation, interviews conducted, and record during the investigation it was determined that the two staff had not noticed the infant leaving the facility through the front entry to be discovered later and was observed being returned by a citizen from the far end of the parking lot. This poses an immediate risk to the health and safety of the children in care.
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Upon receipt, licensee shall post and provide copies of this licensing report,have LIC 9224 signed and kept on file, to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

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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: Sandy KnightTELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2020
LIC809 (FAS) - (06/04)
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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 - INFANTS
FACILITY NUMBER: 430709448
VISIT DATE: 11/06/2020
NARRATIVE
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Continuation of page 1 report dated 11/6/2020

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, A violation regarding CARE AND SUPERVISION warrants an immediate civil penalty of $500.00 and is hereby assessed, See LIC421IM. 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 provided to the Licensee by email, Lorena Lopez, as proof this form has been confirmed received by "return receipt" of these documents due to Covid-19 shelter in place orders.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020
LIC809 (FAS) - (06/04)
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