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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434417025
Report Date: 09/21/2023
Date Signed: 11/08/2023 09:42:08 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 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
08/28/2023 and conducted by Evaluator Anna Morales
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20230828101829
FACILITY NAME:PRIMROSE SCHOOL OF CUPERTINOFACILITY NUMBER:
434417025
ADMINISTRATOR:MONICA THOMPSONFACILITY TYPE:
850
ADDRESS:1002 SOUTH DE ANZA BOULEVARDTELEPHONE:
(408) 685-7133
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY:100CENSUS: 69DATE:
09/21/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH: Sima ShahTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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1. Staff inappropriately handles daycare children while in care
2. Staff did not properly report an incident involving a child in care
INVESTIGATION FINDINGS:
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LPA's(Licensing Program Analysts) Anna Morales and Jessica Bongardt conducted an subsequent complaint visit to deliver the findings for the above allegations. LPA's met with Owner Sima Shah.

The complaint investigation is concluded and the findings were based on interviews conducted with staff and review of supporting documentation.

(continued on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
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 4
Control Number 07-CC-20230828101829
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PRIMROSE SCHOOL OF CUPERTINO
FACILITY NUMBER: 434417025
VISIT DATE: 09/21/2023
NARRATIVE
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Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the above allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE CENTER, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 07-CC-20230828101829
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PRIMROSE SCHOOL OF CUPERTINO
FACILITY NUMBER: 434417025
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/22/2023
Section Cited
CCR
101223(a)(3)
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Allegation is unsubstantiated - no deficiency cited.
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No correction needed.
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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: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 07-CC-20230828101829
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PRIMROSE SCHOOL OF CUPERTINO
FACILITY NUMBER: 434417025
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
10/05/2023
Section Cited
CCR
101212(d)(1)(C)
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Allegation is unsubstantiated - no deficiency cited.
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No correction needed.
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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: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4