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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408755
Report Date: 05/29/2024
Date Signed: 05/29/2024 12:19:35 PM


Document Has Been Signed on 05/29/2024 12:19 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 PRIMARY PLUSFACILITY NUMBER:
434408755
ADMINISTRATOR:RITIPAL(NEEKA)JUNEJAFACILITY TYPE:
850
ADDRESS:5845 ALLEN AVENUETELEPHONE:
(408) 629-6020
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:254CENSUS: 166DATE:
05/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Georgia Andresen RobelloTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mel Matos and Martha Jimenez-Villanueva met with Director Georgia Andresen Robello for an unannounced Case Management Investigation. Purpose of the Incident: investigate an Unusual Incident Report that the Facility self reported to the Department on April 30, 2024.

The Unusual Incident occurred on Monday April 29, 2024. Director states that the teacher in the K3 classroom took her class to the fenced playground area around 10:10 AM. There were 11 preschool children in the K3 classroom and the teacher did a name to face roll call before exiting the classroom. The teacher did not do a name to face roll call upon arriving at the fenced playground area and did not realize that one preschool child had stayed behind in the K3 classroom until she did the name to face roll call before leaving the playground area. Another teacher, who was also in the playground area, went to the K3 classroom and observed the preschool child sitting at table located close to the front door of the room. Director states that the child was fine and not upset that the child got left unattended in the K3 classroom. Director states that the teacher was sent home for the day pending an investigation and was terminated the following day.

Based on the available evidence, LPAs conclude that there was a lack of supervision during morning transition time on April 29, 2024 when a child was left unattended in the K3 classroom. This presents an immediate health & safety risk to children in care. The following Type A deficiency is cited on the attached page (809-D). Director Georgia Andresen was informed that failure to correct the deficiency by the specified Plan of Correction (POC) Due Date May 30, 2024, result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

An immediate civil penalty of $500 is assessed as a result of the incident noted above. A civil penalty of $250 is also assessed since this is a repeat violation of lack of supervision within a 12 month period.

REPORT CONTINUED ON THE FOLLOWING PAGE (LIC 809-C)

SUPERVISOR'S NAME: Belinda DevallTELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Martha Jimenez-VillanuevaTELEPHONE: 408-324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 PRIMARY PLUS
FACILITY NUMBER: 434408755
VISIT DATE: 05/29/2024
NARRATIVE
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LPA’s informed Director Georgia Andresen Robello to provide a copy of this licensing report dated 05/29/2024 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with Director Georgia Andresen Robello and copy of appeal rights was provided. A notice of site visit was given and must remain posted along with today's report for 30 days.
SUPERVISOR'S NAME: Belinda DevallTELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Martha Jimenez-VillanuevaTELEPHONE: 408-324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/29/2024 12:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 PRIMARY PLUS
FACILITY NUMBER: 434408755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/30/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care & Supervision. No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Director agreed to submit a written Plan of Correction to LPA Jimenez-Villanueva by Thursday May 30, 2024 indicating additional procedure(s) that have been/will be implemented to ensure that children are supervised at all times including transitions times.
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This requirement was not met as evidenced by: a child was left unattended in the K3 classroom during morning transition time on 04/29/24. This presents a potential risk to the health, safety or 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: Belinda DevallTELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Martha Jimenez-VillanuevaTELEPHONE: 408-324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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