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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434415175
Report Date: 10/25/2023
Date Signed: 10/25/2023 10:07:53 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/18/2023 and conducted by Evaluator Melvin S Matos
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20230718135819
FACILITY NAME:ACTION DAY PRIMARY PLUSFACILITY NUMBER:
434415175
ADMINISTRATOR:BATE, STEPHANIEFACILITY TYPE:
830
ADDRESS:2164 LINCOLN AVENUETELEPHONE:
(408) 266-8188
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:18CENSUS: 11DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Diana MartinezTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Staff caused injury to child
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mel Matos met with Diana Martinez, Director, for a follow up complaint investigation to deliver investigation findings. The investigation was conducted by Investigator James Santos. Based on interviews, observations, record reviews, and evidence gathered during the investigation process, the Department concludes that a staff caused injury to an infant child while trying to get the infant child to sleep during nap time on July 17, 2023. The Facility terminated the staff person as a result of the incident. The above allegation is thus found to be SUBSTANTIATED, meaning the allegation is valid because the preponderance of the evidence standard has been met.

A "Type A" deficiency is being cited on the attached LIC 9099-D. Exit interview conducted and report was reviewed with Director, Diana Martinez. Appeal rights were also provided to Marie prior to conclusion of today's inspection. Notice of site visit was issued and must remain posted for 30 days
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 07-CC-20230718135819
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 434415175
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2023
Section Cited
CCR
101223(a)(2)
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Personal Rights: The licensee shall ensure that each child is accorded the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs
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Facility agrees to submit a written Plan of Correction (POC) to LPA Matos outlining nap time procedures and how children shall not be forced to nap at any time. Plan of Correction is due to LPA Matos by Thursday October 26, 2023.
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This requirement was not met as evidenced by: a staff caused injury to an infant child while trying to get the infant child to sleep during nap time on July 17, 2023. The Facility terminated the staff person as a result of the incident. This presents an immediate risk to the health, safety, or personal rights of children in care.
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Licensee must provide copies of this report to parents/guardians of children in care at this facility and to parents/guardians of children newly enrolled at this facility during the next 12 months per the AB633 requirements.
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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.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/18/2023 and conducted by Evaluator Melvin S Matos
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20230718135819

FACILITY NAME:ACTION DAY PRIMARY PLUSFACILITY NUMBER:
434415175
ADMINISTRATOR:BATE, STEPHANIEFACILITY TYPE:
830
ADDRESS:2164 LINCOLN AVENUETELEPHONE:
(408) 266-8188
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:18CENSUS: 11DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Diana MartinezTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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2
3
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9
Staff did not supervise child resulting in injury

The facility is out of ratio
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mel Matos met with Diana Martinez, Director, for a follow up complaint investigation to deliver investigation findings. The investigation was conducted by Investigator James Santos. Based on interviews, observations, record reviews, and evidence gathered during the investigation process it is concluded that although the allegations noted on this complaint may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. The allegations are thus UNSUBSTANTIATED.

Exit interview conducted and report was reviewed with the Director, Diana Martinez. No deficiencies issued. A notice of site visit was given and must remain posted for 30 days.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3