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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408755
Report Date: 04/24/2024
Date Signed: 06/19/2024 09:49:03 AM


Document Has Been Signed on 06/19/2024 09:49 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/10/2024 02:02 PM

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

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Licensing Program Analysts (LPAs) Samantha Yip and Andrea Cortez conducted Case Management-Other inspection. LPA met with Director Georgia Robello and Farrah Derla and explained the reason for the inspection. The purpose of this inspection is to discuss ratio.

LPAs reviewed staff files during today's inspection. LPA discussed with Director about plans to ensure that the center is within ratio at all times. At 9:29AM, LPA observed that a parent dropped off a child in Room 9. There were 13 children and one staff. Director brought the child to Room 3.

As a result of this inspection, no deficiencies were issued. Exit interview conducted and report was reviewed with Director Farrah Derla. A notice of site visit has been issued.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
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 2


Document is an Amendment of Original Document on 06/10/2024 02:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)

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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 SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2