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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710222
Report Date: 09/01/2023
Date Signed: 09/01/2023 11:56:36 AM


Document Has Been Signed on 09/01/2023 11:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:PRIMARY PLUS, INC.FACILITY NUMBER:
430710222
ADMINISTRATOR:JENNA FENNELLFACILITY TYPE:
850
ADDRESS:1125 WEST CAMPBELL AVETELEPHONE:
(408) 379-3184
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:320CENSUS: 84DATE:
09/01/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Alyssa ContrerasTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Ashley Lopez, met with Preschool Director, Alyssa Contreras and explained purpose of today's visit- to follow-up on water lead testing conducted for the facility. LPA obtained a copy of Facility Sketch (LIC 999-fully labeled with locations of all water outlets) to identify the faucets with Action Level Exceedance (ALE) with a value of 5.5 parts per billion or greater.

Water lead testing was conducted on 10/29/22 and indicated that faucet "G" (a faucet in office bathroom) had an ALE of 10, “N” (faucet in Room 8) had an ALE of 240, and “O” (Faucet in Room 9) had an ALE of 27. The director stated that rooms 8 and 9 have been closed for a few years and the faucets have not been used. All faucets with an exceedance have been fully replaced and are currently waiting to be retested for lead. Drinking water is being provided by Brita filtered pitchers located in each classroom. LPA requested that the facility update Licensing when a retest date has been confirmed for faucet "G", “N”, and “O” and advised that the results be submitted once retesting is completed.

Prior to inspection LPA obtained the following documents:


1.Self-Certification (LIC9275)
2.Sampling Checklist Form (LIC9276)
3. Full lead report from water program

Exit interview conducted and report was reviewed with the Director, Alyssa Contreras. As a result of todays inspection, a deficiency was cited, see 809-D.


A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Ashley LopezTELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
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 09/01/2023 11:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: PRIMARY PLUS, INC.
FACILITY NUMBER: 430710222

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2023
Section Cited
CCR
101700(b)(1)

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Lead Testing Written Directives (b)(1)a result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.

This requirement was not met as evidenced by:
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Director stated all three faucets have been replaced and are awaiting retesting. Director states she will send updated retesting information to licensing by the due date 10/13/23.
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After water lead testing was completed, the facility had three faucets G, N, and O located in the preschool with an Action Level Exceedance of 10, 240, and 27, which poses a potential risk to the health, safety, and personal rights of children in care.
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Director states the water company Enthalpy Analytical has been in contact and have not given at retesting date.

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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: Ashley LopezTELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
LIC809 (FAS) - (06/04)
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