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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414670
Report Date: 08/08/2024
Date Signed: 08/08/2024 12:09:51 PM


Document Has Been Signed on 08/08/2024 12:09 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:
434414670
ADMINISTRATOR:BATE, STEPHANIEFACILITY TYPE:
830
ADDRESS:2174 LINCOLN AVENUETELEPHONE:
(408) 266-8188
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:50CENSUS: 39DATE:
08/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lucy NunezTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Jennifer "Jen" Beehler & Samantha Yip conducted an unannounced Case Management- Incident inspection. LPAs were provided access to the property by on site Director Lucy Nunez. LPAs explained the reason for the inspection. The purpose of this inspection is to investigate a self reported incident involving S-1, C-1, C-2, and a violation of personal rights. The incident was reported to the San Jose Regional Office on 07/31/2024.

During today's inspection, LPAs conducted interviews with staff. LPAs also reviewed staff file and Employee Warning form. LPAs were provided with a copy of the personnel record and classroom roster. Based on the information obtained, S-1 had violated children's personal rights.

Director Nunez stated S-1 was terminated on 07/25/2024. Director Nunez stated she will be conducting training with staff about personal rights.

Due to this inspection, a Type A citation was issued. Exit interview was conducted and report was reviewed with Site Director, Lucy Nunez. A notice of site visit has been issued and must remain posted for 30 days.

LPA Jen Beehler informed Site Director, Lucy Nunez, that this report dated 08/08/2024 documents one Type A citations which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Jen informed the Site Director to provide a copy of this licensing report dated 08/08/2024 that documents any Type A citation(s) 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.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Jennifer BeehlerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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 08/08/2024 12:09 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: 434414670

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2024
Section Cited
CCR
101223(a)(3)

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Personal Rights. To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
This requirement is not met as evidenced by:
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Submit a letter with schedule of training and plan to address personal rights issues with staff.
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Based on interviews and record review, S-1 did violate children's personal rights, which is an immediate 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 SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Jennifer BeehlerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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