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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415146
Report Date: 06/01/2023
Date Signed: 06/01/2023 02:01:15 PM

Document Has Been Signed on 06/01/2023 02:01 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:PRIMROSE SCHOOL OF WILLOW GLENFACILITY NUMBER:
434415146
ADMINISTRATOR:SHANAWANY,AYAHFACILITY TYPE:
850
ADDRESS:1496 HAMILTON AVENUETELEPHONE:
(669) 273-6169
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 174TOTAL ENROLLED CHILDREN: 209CENSUS: 187DATE:
06/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ayah ShanawanyTIME COMPLETED:
10:00 AM
NARRATIVE
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 Licensing Program Analyst (LPA) Kassandra Medrano conducted a Case Management inspection today. LPA met with Ayah Shanawany, Site Director and Monica Thompson, Executive Director the purpose of the visit was explained. On 5/16/2023, during review of staff associations, it was observed that staff Nicole Kephart had not receive fingerprint clearance.Teacher Nicole was removed from ratio, director stated that they were not aware that she could not be in the classroom while "In Process." During review of records it was observed that she had been employed and in ratio at the facility since 03/13/2023. Per review of fingerprint list, the guardian application showed Nicole Kephart "In Process" which means that there was not a full criminal record clearance. Due to a problem with the document, the civil penalties did not populate, the report made today is to correct the fees assessed.

Exit interview conducted and report was reviewed with the facility representatives, Monica Thompson and Ayah Shanawany.

California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):

"NOTICE OF SITE VISIT" DOCUMENT WAS POSTED ADJACENT TO THE MAIN ENTRY DOORWAY AND VISIBLE TO PARENTS. LICENSEE MUST POST ANY TYPE A DEFICIENCIES DURING TODAYS VISIT WITH THE NOTICE AND LICENSEE UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR AB 633 FACT SHEET AND A COPY OF ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH APPLICANT/PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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 06/01/2023 02:01 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 06/01/2023 at 10:09 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: PRIMROSE SCHOOL OF WILLOW GLEN
FACILITY NUMBER: 434415146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2023
Section Cited
CCR
101170(e)(1)

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101170 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department

This requirement was not met as evidenced by:
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Staff, Nicole Kephart was immediatley removed from the facility. Director stated she will not return until she receives her full clearance.
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During review of staff associations during interviews it was found that staff, Nicole Kephart was "In Process" and did not have full fingerprint clearance and did not have appropriate exemption. She has been in ratio since 3/13/23. This poses an imediate 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:Diana Stephenson
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
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