434415175-1-7-2025-07-CC-JBER-DCPQ69-20250107105311

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415175
Report Date: 01/07/2025
Date Signed: 01/07/2025 10:53:24 AM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/07/2025 10:53 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	ACTION DAY PRIMARY PLUS		FACILITY NUMBER:	434415175
ADMINISTRATOR/ DIRECTOR:	JAMIE FERGUSON		FACILITY TYPE:	830
ADDRESS:	2164 LINCOLN AVENUE		TELEPHONE:	(408) 266-8188
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY: 18	TOTAL ENROLLED CHILDREN: 18	CENSUS: 14	DATE:	01/07/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:35 AM
MET WITH:	Jamie Ferguson		TIME VISIT/ INSPECTION COMPLETED:	11:05 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Jennifer “Jen” Beehler, met with Director, Jamie Ferguson, for an unannounced Required- 1 Year Inspection. LPA was granted access to the facility by the Director and toured the indoor part of the facility during the inspection. Upon arrival, there were 14 children (infants) and 4 staff (3 fully qualified teachers and 1 aide) present, which is compliant with the facility license capacity and ratio requirements. LPA observed all required postings near the entrance to the facility. Hours of operation for the facility are Monday – Friday, 07:00AM-06:00PM. The facility currently has a waiver to use a digital pin code for sign in/out. Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. All staff people present had criminal record clearance and were associated to the facility roster on Guardian. LPA reviewed sign-in/out sheets, facility roster (LIC9040), and fire/disaster drill log during today’s inspection. Sign-in/out was observed to be completed with full legal signature and time of day. The last fire/disaster drill was conducted on 08/21/2024, which is compliant with the six month requirement for facilities. LPA observed a fully charged 3A40BC fire extinguisher last serviced 12/10/2024, which is compliant with state marshal regulations. LPA observed a fully functioning smoke detector system and a working carbon monoxide detector. Director states that she does not currently have any children in care who require Incidental Medical Services. When children in care do require medication, it is properly stored out of reach of children, in a locked box, with the proper documentation. Continued on Page 2

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

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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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: 434415175
	VISIT DATE: 01/07/2025

NARRATIVE

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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Indoor areas of the facility were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the facility via water pitchers from filtered water that is distributed to children in sippy cups labeled with their names. Staff and children’s bathrooms are clean, sanitary, and operable. There is a separate staff bathroom, not utilized by the children. The Facility has a working telephone. Cleaning and maintenance for the facility is conducted by an outside service and is completed in the evenings after all day care children have left the premises. The Director states that there are no weapons or firearms on the premise.

Infant Safe Sleep regulations (PIN 20-24-CCP) were discussed with the Director, including the Individual Infant Sleeping Plan (LIC9227). LPA reminded Director that infants up to 12 months of age should be placed on their back to sleep, that cribs should be free of all loose articles and hanging objects, and that infants should not be swaddled. Infants should be supervised while sleeping and documentation of sleep checks every 15 minutes should remain in the infant’s file. Documentation should include the time of the check, the infant’s physical condition, and initials of the staff member checking on the infant. LPA reminded Director more information could be found at the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep. LPA also informed the Director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

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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: 434415175
	VISIT DATE: 01/07/2025

NARRATIVE

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The outdoor area of the facility was inspected on 01/02/2025 and observed to be fenced in. LPA observed play equipment was in good condition, age-appropriate, and has sufficient resilient materials (rubber padding) to absorb falls. No outdoor bodies of water were observed during today’s inspection. Shaded rest area is provided by canopy.

Food is provided by the parents and brought from home. LPA observed food to be stored, prepared, and served in a safe and healthful manner to the children. Facility offers a snack program if parent permits. Facility will offer cheerios and fresh fruit as an example. Menu is in writing and posted at least one week in advance, accessible to authorized representatives. The kitchen and storage area is clean and free of litter and rubbish. Equipment necessary for the storage, preparation and service of food is well maintained, clean, and sanitized after each use.

5 children’s files (infants) were reviewed during today’s inspection for the following records: Physician’s Report (LIC701), Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Signed Admission Agreement, and Immunization Records (PM286). Individual Infant Sleep Plan (LIC9227), Infant's needs and services and sleep check documentation were present. 3 out of 5 children's files were one year old and MMR vaccination was not present.

3 staff files (1 teacher/ 1 aide) were reviewed for the following records: Transcripts/Verification of Experience, Health Screening Report (LIC503), Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), Mandated Reporter Training Certificate, Tuberculosis (TB) Clearance, and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). There is at least one staff member present with current CPR/First-Aid that expires 05/14/2026. LPA found all staff files to have an updated mandated reporter training. LPA reminded Director Ferguson that the Mandated Reporter Training must be renewed by all staff every 2 years.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

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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: 434415175
	VISIT DATE: 01/07/2025

NARRATIVE

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The Director understands that the site director shall be on the premises during the hours the center is in operation and that children at the center shall be visually supervised at all times. LPA reminded Director Ferguson that there shall be at least one person with valid CPR and First-Aid certifications on site at all times or present during off site activities, such as field trips.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for
drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.
For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).
LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP. LPA received a copy of the lead testing report for the facility and reviewed the results which stated all water fixtures passed.

During today's inspection, the following documents were collected from the facility:

Lead testing report dated 12/29/2022 showing all fixtures met lead exceedance regulation
LIC 9040 Roster
LIC 308 Showing Jenny Do as the second designee of the facility

As a result of today's inspection, no deficiencies were cited, one technical violation is attached and more information is provided on the LIC9102 that is attached to the original site visit dated 01/02/2025. Exit interview conducted with Director, Jamie Ferguson, report reviewed and provided. NOTICE OF SITE VISIT PROVIDED AND MUST REMAIN POSTED FOR 30 DAYS.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

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