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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710074
Report Date: 04/25/2024
Date Signed: 04/25/2024 02:42:17 PM

Document Has Been Signed on 04/25/2024 02:42 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:PRIMARY PLUS - HIBISCUS (PRESCHOOL)FACILITY NUMBER:
430710074
ADMINISTRATOR/
DIRECTOR:		MERCEDES MENDOZAFACILITY TYPE:
850
ADDRESS:801 HIBISCUS LANETELEPHONE:
(408) 985-5998
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 213TOTAL ENROLLED CHILDREN: 213CENSUS: 65DATE:
04/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:11 AM
MET WITH:Sarah HollowayTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management-Other inspection. LPA met with Director Sarah Holloway and explained the reason for the inspection.

LPA observed that S1 and S2 were present at the facility; however, their fingerprints were still pending. Director sent S1 and S2 home. Director will send S1 and S2 to get re-fingerprinted and understands that S1 and S2 cannot return until they have cleared fingerprints. Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA also discussed with Director that all children need to be visually supervised at all times. At 11:20AM, LPA observed that there were children in the toddler play yard where staff cannot visually supervise children. Children were currently lining up to go inside. Director helped bring the children to the staff outside.

As a result of this inspection, a Type A citation and Type B were issued. A civil penalty of $1000 was issued for caregiver background check and $250 for repeat violation. A notice of site visit has been issued and must remain posted for 30 days.

LPA Samantha Yip informed Director Sarah Holloway that this report dated 04/25/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Samantha informed the Director to provide a copy of this licensing report dated 04/25/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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 04/25/2024 02:42 PM - It Cannot Be Edited


Created By: Samantha Yip On 04/25/2024 at 10:50 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: PRIMARY PLUS - HIBISCUS (PRESCHOOL)
FACILITY NUMBER: 430710074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2024
Section Cited
CCR
101170(e)(1)

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Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department...
This requirement is not met as evidenced by:
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By POC 04/25/2024, Director will have S1 and S2 refingerprint.

S1 and S2 were sent home
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Based on record reviews, S1 and S2's were present, but fingerprints were still pending. This poses an immediate health and safety risk to chidren in care.
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during today's inspection.

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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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2024 02:42 PM - It Cannot Be Edited


Created By: Samantha Yip On 04/25/2024 at 12:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: PRIMARY PLUS - HIBISCUS (PRESCHOOL)
FACILITY NUMBER: 430710074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time...Supervision shall include visual observation.
This requirement is not met as evidenced by:
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By POC 05/02/2024, Director will submit date when staff training will be conducted with staff.
Director will submit list of
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Based on observation, LPA observed at 11:20 that there were children in the toddler play yard. There was no staff standing where they can visually supervise the children. Director brought the child to the staff. This poses a potential health and safety risk to children in care.
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staff who attended training upon completion.

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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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


LIC809 (FAS) - (06/04)
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