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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415175
Report Date: 02/16/2022
Date Signed: 02/16/2022 10:09:47 AM

Document Has Been Signed on 02/16/2022 10:09 AM - It Cannot Be Edited

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
FACILITY NAME:ACTION DAY PRIMARY PLUSFACILITY NUMBER:
434415175
ADMINISTRATOR:PAULA SCHROEDERFACILITY TYPE:
830
ADDRESS:2164 LINCOLN AVENUETELEPHONE:
(408) 266-8188
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 18TOTAL ENROLLED CHILDREN: 18CENSUS: 15DATE:
02/16/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jill MillerTIME COMPLETED:
10:15 AM
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Licensing Program Analysts (LPAs) Ofelia Calivo and Marilou Monico conducted a Plan of Correction (POC) inspection. The facility was cited on February 8, 2022 under Limitations on Capacity. LPAs met with Preschool Director, Jill Miller.

LPAs toured the facility. LPAs observed 15 children (3 in the nap room, 4 in the kitchen, and 8 in the activity room). There were 4 staff members (3 teachers & 1 teacher's aide) present with the children. LPAs observed parents/authorized representatives signed the Acknowledgement of Receipt of Licensing Report (LI 9224).

As a result of this inspection, deficiency under Limitations on Capacity is hereby corrected and cleared.

There were no deficiencies cited.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Ofelia Calivo
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2022
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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