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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430710145
Report Date: 03/15/2023
Date Signed: 03/15/2023 10:20:28 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 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
02/21/2023 and conducted by Evaluator Pietro Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20230221122940
FACILITY NAME:PRIMARY PLUSFACILITY NUMBER:
430710145
ADMINISTRATOR:GUZMAN, SHUREEFACILITY TYPE:
840
ADDRESS:18720 BUCKNALL RDTELEPHONE:
(408) 370-0357
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY:56CENSUS: 9DATE:
03/15/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Shuree GuzmanTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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1) Staff did not notify day care child's authorized representative of incident in a timely manner.

2) Staff did not seek medical attention for day care child.

3) Staff did not provide sufficient supervision to prevent a day care child from choking on foreign objects.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pete Hernandez conducted a subsequent complaint investigation visit today and met with Shuree Guzman. The purpose of today’s visit was to deliver investigation findings for the above allegations.

On 03/01/2023, LPA conducted an unannounced visit at the facility to obtain facility records and interview staff. Director provided a copy of the children's roster, e-mails, children’s file, parent's handbook, and other relevant documentation from the child's (C1) file.

The complaint alleged that before noon on 02/14/2023, C1 choked on something while in care and was given a Heimlich maneuver to dislodge the object. C1’s legal representative was not informed until pick up and no further medical attention was sought for C1 by the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
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 2
Control Number 07-CC-20230221122940
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
FACILITY NUMBER: 430710145
VISIT DATE: 03/15/2023
NARRATIVE
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LPA’s investigation revealed that C1 has a 1:1 aide, (A1). Based on interviews, staff who witnessed the incident stated there was visual supervision on C1 at all times by facility staff and there was no Heimlich maneuver performed on C1. All staff interviewed stated C1 threw the candy up on the floor. A1 stated seeing C1 grab and eat a candy and attempted to run away then started choking on the candy. A1 stated not remembering the term “Heimlich maneuver” and explained what happened to the Director without using the term.

The Department has investigated and determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted. This report was discussed and left with the Licensee, Shuree Guzman, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2