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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430710075
Report Date: 04/25/2024
Date Signed: 04/25/2024 02:46:59 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/13/2024 and conducted by Evaluator Samantha Yip
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20240313145827
FACILITY NAME:PRIMARY PLUS - HIBISCUS (INFANTS)FACILITY NUMBER:
430710075
ADMINISTRATOR:MERCEDES MENDOZAFACILITY TYPE:
830
ADDRESS:801 HIBISCUS LANETELEPHONE:
(408) 985-5998
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:106CENSUS: 30DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Sarah HollowayTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility failed to maintain ratio
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced complaint investigation for the above allegation. LPA met with Director Sarah Holloway and explained the reason for the inspection. Upon arrival, there were 10 infants and at least four staff.

During the course of this investigation, LPA reviewed Daily Attendance Rooster, Daiy Infant Log, staff schedule, and staff files. LPA also conducted observation. Based on the information obtained, the above allegation is found to be SUBSTANTIATED, meaning the preponderance of the evidence standard has been met.
--------------CONTINUES ON 9099 DATED 04/25/2024 PAGE 2--------------
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 07-CC-20240313145827
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/25/2024
NARRATIVE
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--------------CONTINUATION OF 9099 DATED 04/25/2024 PAGE 1------------

Based on record reviews and observation, LPA observed on 04/25/2024 that S1 was present in the room and is in the process of completing the infant care course. There was no other staff present in the room who is a qualified infant teacher. Director understands that S1 cannot qualify as a infant teacher until they have completed at least 3 semester units in infant care.

As a result of this investigation, a Type A citation was issues. Exit interview conducted and report was reviewed with Director Sarah Holloway. 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.

SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/13/2024 and conducted by Evaluator Samantha Yip
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20240313145827

FACILITY NAME:PRIMARY PLUS - HIBISCUS (INFANTS)FACILITY NUMBER:
430710075
ADMINISTRATOR:MERCEDES MENDOZAFACILITY TYPE:
830
ADDRESS:801 HIBISCUS LANETELEPHONE:
(408) 985-5998
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:106CENSUS: 30DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Sarah HollowayTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff do not provide adequate supervision to prevent injuries
Staff failed to wash hands after diaper change
Facility failed to notify incident to parent
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Samantha Yip conducted an uannounced complaint investigation for the above allegations. LPA met with Director Sarah Holloway and explained the reason for the inspection.

During the course of this investigation, LPA reviewed diaper proceduers, diaper log, accident/injury log, and supervision procedures. LPA conducted observation. LPA also interviewed staff and third party. As a result this investigation, the above allegations are found to be UNSUBSTANTIATED, meaning although,the above allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted and report was reviewed with Director Sarah Holloway. A notice of site was issued and must remain posted for 30 days.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 07-CC-20240313145827
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2024
Section Cited
CCR
101416.5(b)(1)
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Staff-Child Ratio. There shall be a ratio of one teacher for every four infants in attendance. An aide may be substituted for a teacher when all of the following conditions are met: There is a fully qualified teacher directly supervising no more than 12 infants...
This requirement is not met as evidenced by:
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By POC 04/25/2024, Director will submit written plan on how she will ensure center is within ratio and there is at least one fully qualified infant teacher.
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Based on record reviews and observation, S1 was present and is in the process of completing course in infant care. The other staff present has not completed any courses. This poses an immediate health and safety risk to 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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
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
LIC9099 (FAS) - (06/04)
Page: 5 of 5