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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710075
Report Date: 12/03/2019
Date Signed: 12/03/2019 11:57:15 AM

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 (INFANTS)FACILITY NUMBER:
430710075
ADMINISTRATOR:JACQUELINE CATTOLICOFACILITY TYPE:
830
ADDRESS:801 HIBISCUS LANETELEPHONE:
(408) 985-5998
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:106CENSUS: 41DATE:
12/03/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Christiane SherwoodTIME COMPLETED:
11:00 AM
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On 12/03/19 Licensing Program Analysts [LPAs] Monica Mathur and Pete Hernandez conducted an unannounced Plan of Correction [POC] inspection at Primary Plus - Hibiscus (infants) for citations issued on 11/14/19. LPA met with Director, Christiane Sherwood, and explained the purpose of today's inspection.

On 11/14/19 Two citations were issued during an annual/random inspection, noted below:.Criminal Record Clearance
Modifications to Infant Needs and Services Plan:
Director submitted to CCL a written plan of corrections for above citations.

During today's POC Inspection, all staff present in the room have criminal record clearances and were associated to the facility. All needs and services plans are current and updated. Facility is in compliance with regulations and citations issued on 11/14/19 were cleared during this inspection.

Exit Interview was conducted, where this report was reviewed and signed by the Director confirming receipt of documents. LPA also provided the Letters of Clearance. A NOTICE OF SITE VISIT WAS ISSUED, AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2019
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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