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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710074
Report Date: 03/06/2024
Date Signed: 03/06/2024 01:48:38 PM

Document Has Been Signed on 03/06/2024 01:48 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:PRIMARY PLUS - HIBISCUS (PRESCHOOL)FACILITY NUMBER:
430710074
ADMINISTRATOR:MERCEDES MENDOZAFACILITY TYPE:
850
ADDRESS:801 HIBISCUS LANETELEPHONE:
(408) 985-5998
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 213TOTAL ENROLLED CHILDREN: 213CENSUS: 77DATE:
03/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Nipunika "Riya" ChaudhuryTIME COMPLETED:
11:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Samantha Yip and Andrea Cortez conducted an unannounced Case Management-Other inspection. LPA met with Assistant Director Nipunika "Riya" Chaudhury and explained the reason for the inspection. The purpose of this inspection is to discuss supervision.

At 11:40AM, LPA Yip observed that there was a child in the restroom. The staff walked out of the bathroom and back into the room. There were other staff in the room, but there was no staff standing where they could visually supervise the child in the restroom. LPA observed that a staff went back into the restroom to help the child. LPA discussed with Assistant Director that staff need to position themselves where they can visually supervise children at all time, including when they are in the bathroom.

Facility will submit by 03/16/2024:
- Director packet

As a result of inspection, a Type B citation was issued. Exit interview conducted and report was reviewed with Assistant Director Riya Chudhury. A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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 03/06/2024 01:48 PM - It Cannot Be Edited


Created By: Samantha Yip On 03/06/2024 at 01:12 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: PRIMARY PLUS - HIBISCUS (PRESCHOOL)
FACILITY NUMBER: 430710074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation.
This requirement is not met as evidenced by:
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By 03/13/2024, facility stated that they will do training with staff regarding supervision and send meeting notes and list of staff who attended training.
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Based on observation, LPAs observed at 11:40AM that a staff walked out of the bathroom while a child was inside. There was no staff standing where they could visually supervise the child. Staff were in the room. This poses a potential 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 Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
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