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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417026
Report Date: 04/24/2024
Date Signed: 08/15/2024 10:44:22 AM

Document Has Been Signed on 08/15/2024 10:44 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:PRIMROSE SCHOOL OF CUPERTINOFACILITY NUMBER:
434417026
ADMINISTRATOR/
DIRECTOR:		MONICA THOMPSONFACILITY TYPE:
830
ADDRESS:1002 SOUTH DE ANZA BOULEVARDTELEPHONE:
(408) 685-7133
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 22DATE:
04/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:11 PM
MET WITH:Monica ThompsonTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
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This is an amended report.

Licensing Program Analysts (LPAs) Samantha Yip and Andrea Cortez conducted an unannounced Case Management- Incident inspection. LPA met with Executive Director Monica Thompson and explained the reason for the inspection. The purpose of this inspection is to review a self-report incident that occurred on 04/18/2024 and an absence of supervision. Facility reported incident to the San Jose Regional Office on 04/18/2024.

During today's inspection, LPAs conducted interviews and reviewed staff file. Based on interviews and staff file, S-1 was in the room with the children and was supervising the child.

Executive Director stated that she will be conducting training with staff in their next staff meeting and will discuss policies. She stated that the topic has been discussed at previous staff meetings.

As a result of this inspection, no deficiencies were issued. Exit interview conducted and report was reviewed with Executive Director Monica Thompson. A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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 04/24/2024 03:14 PM - It Cannot Be Edited


Created By: Samantha Yip On 04/24/2024 at 02:51 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: 04/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/24/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time.... Supervision shall include visual observation.
This requirement is not met as evidenced by:
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By POC 04/24/2024, Director will submit plan on how she will ensure staff are supervising at all times.
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Based on interview and record review, S-1 fell asleep during naptime and was the only staff present in the room at the time. This poses an immediate health and safety risk to children in care.
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S-1 was terminated on 04/18/2024.


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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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
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