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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417026
Report Date: 09/21/2023
Date Signed: 09/22/2023 11:45:47 AM

Document Has Been Signed on 09/22/2023 11:45 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:PRIMROSE SCHOOL OF CUPERTINOFACILITY NUMBER:
434417026
ADMINISTRATOR:MONICA THOMPSONFACILITY TYPE:
830
ADDRESS:1002 SOUTH DE ANZA BOULEVARDTELEPHONE:
(408) 685-7133
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 12DATE:
09/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Monica Thompson/ Sima ShahTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Morales conducted a Case Management Inspection while conducting a Complaint Investigation and was met by Executive Director Monica Thompson and Sima Shah,Owner. LPA toured the facility, interviewed staff, reviewed and obtained supporting documents.

Based on the interviews with staff and Director(s)and reviewing supporting documentation, it was determined that on May 17,2023, S1 fell asleep inside Young Toddler Classroom during Children's nap time with no other staff present. This incident was not reported to Community Care Licensing.


Type B deficiency was cited during today's visit. A notice of site visit was given and must remain posted for 30 days.

Exit interview was conducted with Director Monica Thompson and Sima Shah, Owner. Appeal right were given.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/22/2023 11:45 AM - It Cannot Be Edited


Created By: Anna Morales On 09/21/2023 at 02:48 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: 434417026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
10/05/2023
Section Cited
CCR
101212(d)(1)(C)

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Reporting Requirements. Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
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Executive Director stated that she will submit a Written Incident Report for 5/17/23, and a written plan will be sent to Licensing by the POC date, to ensure that any unusual incidents shall be reported to Licensing within the required time frame.
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Any unusual incident or child absence that threatens the physical or emotional health or safety of any child. This requirement is not met as evidenced by: An incident occured on 5/17/23 where staff fell asleep while supervising children in the Young Toddler Classroom during naptime. No other staff were present.This Incident was not reported to Licensing, which poses a potential health and safety 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: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


LIC809 (FAS) - (06/04)
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