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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430701361
Report Date: 04/25/2024
Date Signed: 04/25/2024 05:52:12 PM

Document Has Been Signed on 04/25/2024 05:52 PM - 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ACTION DAY NURSERYFACILITY NUMBER:
430701361
ADMINISTRATOR/
DIRECTOR:		BATE, STEPHANIEFACILITY TYPE:
850
ADDRESS:2146 LINCOLN AVENUETELEPHONE:
(408) 266-8952
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 154TOTAL ENROLLED CHILDREN: 222CENSUS: 36DATE:
04/25/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:50 PM
MET WITH:Smriti Datta and Lucy NunezTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mandeep Kaur met with Site Director, Smriti Datta and Site Supervisor, Lucy Nunez for an unannounced Plan of Correction (POC) inspection. Purpose of today's inspection: address the Plan of Correction (POC) for a "Type A" deficiencies issued to the Facility on April 12, 2024 and April 18, 2024. The plan of correction was due on April 19,2024.

LPA reviewed random nine (9) children files. LPA observed that the Acknowledgment of Receipt of Licensing Reports (LIC 9224) were not signed by the parents of four (4) children(C#4,C#6,C#8,and C#9) out of nine children in care and kept in each child's records.

It is concluded that the facility has not completed the Plan of Correction for the Type A deficiencies, those were issued on April 12, 2024 and April 18,2024.

Site Director stated that she has talked to parents and provided the Type A deficiencies reports and LIC 9224 (Acknowledgement of Receipt of Licensing Reports). Site Director and Site Supervisor stated that parents have not given the signed LIC 9224 back to facility.

As a result of this inspection, Type B deficiency was cited on the following page:

Exit interview conducted, report was reviewed with the Site Supervisor, Lucy Nunez and Appeal rights were provided. A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2024 05:52 PM - It Cannot Be Edited


Created By: Mandeep Kaur On 04/25/2024 at 05:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ACTION DAY NURSERY
FACILITY NUMBER: 430701361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2024
Section Cited
HSC
1596.8595(c)(1-4)

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HSC 1596.8595((c)(1) A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b.(2) Upon enrollment of a new child in a facility...(3)recipient to sign(4)keep verification of receipt on child's file...This requirement was not met as evidenced by:
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Site Supervisor stated that they will submit the copy of missing LIC 9224 (Acknowledgement of Receipt of Licensing Reports) for four children (C34,C#6,C#8 and C#9) by POC due date 05/03/2024 to the department.
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Based on interviews and record reviews, licensee is failed to obtain completed and signed by parents, LIC9224 Acknowledgement of Receipt of Licensing Reports for Type A Deficiencies issued on 04/12/2024 and 04/18/2024 as per AB633 requirements which posed potential health, safety or personal rights risk to persons 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:Belinda Devall
LICENSING EVALUATOR NAME:Mandeep Kaur
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


LIC809 (FAS) - (06/04)
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