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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710492
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:32:05 PM

Document Has Been Signed on 07/24/2023 01:32 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:ACTION DAY NURSERYFACILITY NUMBER:
430710492
ADMINISTRATOR:STRANGE, BRITTANYFACILITY TYPE:
830
ADDRESS:3030 MOORPARK AVENUETELEPHONE:
(408) 249-0668
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 97TOTAL ENROLLED CHILDREN: 72CENSUS: 53DATE:
07/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Brittany StrangeTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marilou Monico met Site Director, Brittany Strange, and conducted a Case Management Inspection. LPA learned that a parent reported to the facility that her child sustained an injury. The facility conducted an internal investigation, however, the facility failed to report and submit an Unusual Incident Report (LIC 624) to Community Care Licensing.

As a result of this inspection, deficiency was cited on the following page.

Exit interview conducted and report was reviewed with Site Director, Brittany Strange.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
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 07/24/2023 01:32 PM - It Cannot Be Edited


Created By: Marilou Monico On 07/24/2023 at 11:29 AM
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: 430710492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2023
Section Cited
CCR
101212(d)(1)&(2)

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Reporting Requirements - Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1), a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) shall be submitted to the Department within seven days following the occurrence of such event.
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Site Director agreed to submit a written plan to CCL by 07/26/23 to ensure that any unusual incidents shall be reported to CCL within the next business day and followed by a written report within seven days.
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This requirement was not met as evidenced by: The facility failed to report an injury to Community Care Licensing (CCL). This poses a potential risk to the health, safety, and personal rights of 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:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023


LIC809 (FAS) - (06/04)
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