430710231-12-9-2020-07-CC-SKNT-BW7SMZ-20201211130045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430710231
Report Date: 12/09/2020
Date Signed: 12/09/2020 10:07:43 AM

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
11/30/2020 and conducted by Evaluator Pietro Hernandez

PUBLIC

COMPLAINT CONTROL NUMBER: 07-CC-20201130153340

FACILITY NAME:	PRIMARY PLUS - CAMPBELL		FACILITY NUMBER:	430710231
ADMINISTRATOR:	LAURIE HAUFF		FACILITY TYPE:	830
ADDRESS:	1125 W. CAMPBELL AVE		TELEPHONE:	(408) 379-3184
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	80	CENSUS: 63	DATE:	12/09/2020
		UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:			TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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1) Measures were not taken to keep the center free of rodents and insects.

INVESTIGATION FINDINGS:

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On 12/9/2020: Licensing Program Analyst (LPA) Pietro Hernandez conducted an unannounced Subsequent Complaint Investigation via Video Conference at the Facility. LPA spoke with Laurie Hauff and discussed the finding for the above allegation. This was also delivered by email return receipt to the Facility during the visit.

During the course of the investigation, LPA inspected the Family Care Home, reviewed records, and conducted interviews with the Licensee, and subordinate staff. LPA Hernandez learned that the licensee has proactively done everything reasonable to keep the facility free of rodents and insects.

Continued on page 2 of LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020

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-20201130153340

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 - CAMPBELL	FACILITY NUMBER: 430710231
	VISIT DATE: 12/09/2020

NARRATIVE

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Continuation of Page 1 LIC9099

1) Measures were not taken to keep the center free of rodents and insects.

LPA Hernandez did not observe any rodents or insects at the facility during the inspection. LPA was told by Director that there was a dead rodent on the grounds a couple months prior to being contacted but was out side of the facility grounds where the staff and children would not be exposed. Director also informed the LPA that the facility is proactive in keeping the center free of rodents and insects. Director provided documentation from the exterminator that is on a monthly contract and contacted as needed to address any extermination needs going back to June of 2020. LPA interviewed several subordinate staff. None had ever seen any rodents on the grounds and have only seen dead insects outside of the buildings used or occupied by the children in care. Staff did say once they had observed a couple dead insects in one of the bathrooms and that was unusual. The reporting party was anonymous and could not be contacted for further investigation.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 07-CC-20201130153340

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 - CAMPBELL	FACILITY NUMBER: 430710231
	VISIT DATE: 12/09/2020

NARRATIVE

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Continuation of Page 2 LIC9099C

Based on the interviews and information obtained throughout the investigation, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

A deficiency is not being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted by Video Conference. A copy of this report and appeals rights were discussed and provided to the Licensee by email, Laurie Hauff, as proof this form has been confirmed received by "return receipt" of these documents due to Covid-19 shelter in place orders.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020

LIC9099 (FAS) - (06/04)

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