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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417025
Report Date: 03/22/2023
Date Signed: 03/23/2023 10:23:55 AM

Document Has Been Signed on 03/23/2023 10:23 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
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: 100TOTAL ENROLLED CHILDREN: 100CENSUS: 99DATE:
03/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Mylynh HuynhTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Farida Raja and Licensing Program Manager (LPM), Gladys Kuizon conducted an unannounced case management visit to obtain more information about an incident report received on 02/09/2023.

Based on incident report the incident occurred in the play yard. Staff S1 didn't realize child C1 from her classroom joined another group into their classroom, while they were crossing the play yard, until another teacher brought C1 back.

Owner, Sima Shah, was interviewed. She stated that there was no absence of supervision for C1 since another teacher was present. However, this is still against their policy and unacceptable for S1 not to be able to account for all children in S1's assigned group.

6 out of 6 who were interviewed today stated that they have never witnessed any child left without supervision.

Based on LPM and LPA's record review, S1 was hired by this facility on 07/21/2022. Owner confirmed S1 worked at the facility. Records revealed that S1 does not have criminal background clearance from time of hire to present. S1 no longer works for this facility. Owner stated that the executive director, Monica Thompson made several attempts to contact Guardian and verify S1's criminal background clearance status and was told it was still 'in process' due to backlog and was not told it was flagged.

A deficiency with civil penalty is being assessed today. See LIC 809-D.

Exit interview conducted with Owner Sima Shah. A copy of this report along with the facility's Appeal Rights are provided.

A Notice of Site Visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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 03/23/2023 10:23 AM - It Cannot Be Edited


Created By: Farida Raja On 03/22/2023 at 02:31 PM
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 CUPERTINO
FACILITY NUMBER: 434417025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2023
Section Cited
CCR
101170(e)(1)

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101170 Criminal Record Clearance (e)(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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Licensee to submit a written plan of action by POC due date.
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Based on records reviewed on Guardian database and facility file, S1 started working at the facility without obtaining criminal record clearance. This posed an immediate 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:Gladys Kuizon
LICENSING EVALUATOR NAME:Farida Raja
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023


LIC809 (FAS) - (06/04)
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