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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710075
Report Date: 11/14/2019
Date Signed: 11/14/2019 04:15:29 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 - 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:
11/14/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Christiane SherwoodTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Monica Mathur and Pietro Hernandez conducted an unannounced, annual inspection, met with the Infant Program Director, Christiane Sherwood and explained the nature of today's inspection. LPAs noted the following ratios in the various infant rooms during time of inspection:
Room 1: 2 teachers / 6 infants
Room 2: 5 teachers /5 infants
Room 3: 2 teachers / 5 infants
Room 4: 3 teachers / 9 infants
Room 6: 2 teachers / 8 infants
The facility was in compliance with teacher/infant ratios, children were not left unattended and were constantly under the direct visual supervision of a staff person. LPAs noted the staff and infants were interacting in various activities. Facility operates in the premises of West Valley Middle School, from Monday - Friday 6:30 AM to 6:00 PM. Facility has active waivers for:
Electronic sign in system
Shared use of rooms 13, 14, 15 with Preschool program.
Outdoor Playground

LPA completed a physical plant inspection touring the building inside and out. No bodies of water were found. Director stated that there are no weapons stored in the facility. Disinfectants, cleaning solutions, poisons, and other items that are dangerous to infants were inaccessible. Furniture and equipment was in good condition, free of sharp, loose, or pointed parts. Facility has age appropriate furniture and equipment, including cribs, mats, feeding chairs, and changing tables. Infant changing tables are located within arms reach of a sink. No baby walkers or bouncers were witnessed during the inspection. All storage containers for solid waste had tight fitting covers and were in good repair. Facility was free of flies, other insects, and rodents. Facility has adequate indoor activity space for infants that is physically separate from space used by the preschool child care center. Bottles, dishes, and containers of food brought by the infant's authorized representative are labeled with the infant's name and current date. Facility has at least one functioning carbon monoxide detector that meets statutory requirements. Facility has adequate outdoor activity space and play equipment that is maintained in a safe condition and is free of hazards. Facility maintains a kitchen for school children.
Continued on Page #2. Report dated 11/14/19
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 5
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 - HIBISCUS (INFANTS)
FACILITY NUMBER: 430710075
VISIT DATE: 11/14/2019
NARRATIVE
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LPA reviewed safe sleep policies for the infants with the Director LPA also discussed the responsibility for providing care and supervision for infants while napping including the need for a staff member to be present when there is an infant napping. There were no infants napping at the time of inspection. LPA gave copy of Safe Sleep Information Flyer.

In the areas that were evaluated, regulatory violations were observed. Therefore, citations were issued. Exit Interview was conducted, where this report, the citations, plan of corrections, and appeal rights were reviewed and discussed with Director. Report was signed by the Director confirming receipt of documents. Director was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made. Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be given to each existing parent by the end of today or next day child is in care, and to the parent of children enrolled over the next 12 months. In addition, requirements of AB633 and a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5
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 - HIBISCUS (INFANTS)
FACILITY NUMBER: 430710075
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2019
Section Cited

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101170(e)(2) Criminal Record Clearance: All individuals subject to a criminal record review [...] shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance [...]. This requirement is not met as evidenced by:
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Per LPAs review of staff files, 2 staff persons S-1 and S-2 were present and caring for children in the infant rooms, but did not have criminal record clearances associated to this facility or any other Primary Plus facilities. This poses an immediate risk to the health and safety of children in care. Civil penalty of $1000 was assessed.
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Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be given to each existing parent by the end of today or next day child is in care, and to the parent of children enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file.

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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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5
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 - HIBISCUS (INFANTS)
FACILITY NUMBER: 430710075
VISIT DATE: 11/14/2019
NARRATIVE
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At the time of inspection, the child care center was clean, safe, sanitary, and in good repair for the well-being of children, employees, and visitors. Drinking water was available for children both indoors and outdoors. All required postings were found posted and in compliance.

LPAs noted that the following staff persons, Kristina Eleogo in Room 1 and Brittany Maracchini in Room 6 were caring for children, but were not associated to the Infant Program or any other Action Day Primary Plus locations. Type A deficiency was cites and Civil Penalties of $1000 was issued. LPA completed a review of facility documentation and found that the facility is operating within the approved capacity of the fire clearance. The person who brings the child to, and removes the child from the center, signs the child in and out. LPA obtained a copy of the facility roster. Menus are posted for the entire month and visible to the child's authorized representative. A review of staff records indicates that all staff subject to a criminal record review have obtained a clearance or criminal record exemption and have completed a medical assessment including a TB test. Personnel records are maintained on the Director and each employee. Facility records also indicate that all teachers have the appropriate education credits and there is at least one person present trained in CPR and Pediatric First Aid when children are at the facility. A review of children's records was completed, and the record did contain the required documents. ten (10) infants do not have an updated Needs and Services plan, and an individual feeding plan. LPA also discussed the updates to the seat belt law.

This facility provides Incidental Medical Services - IMS. LPAs reviewed storage of medication and equipment/supplies, and reviewed children's, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA information line at (800) 514-0301 (voice)/(800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Continued on Page #3. Report dated 11/14/19
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5
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 - HIBISCUS (INFANTS)
FACILITY NUMBER: 430710075
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2019
Section Cited

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101419.3(a) Modifications to Infant Needs & Services Plan: The written infant needs and services plan shall be updated at least quarterly, or as often as necessary to assure its accuracy.
This requirement is not met as evidenced by:
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Per LPAs review of child files, it was observed that 10 infants' Needs & Services Plans were not current or updated in the last 3 months. 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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5