Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710231
Report Date: 12/09/2016
Date Signed 12/09/2016 04:13:13 PM

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:PRIMARY PLUS - CAMPBELLFACILITY NUMBER:
430710231
ADMINISTRATOR:LAURIE HAUFFFACILITY TYPE:
830
ADDRESS:1125 W. CAMPBELL AVETELEPHONE:
(408) 379-3184
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:80CENSUS: 7DATE:
12/09/2016
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Laurie HauffTIME COMPLETED:
04:20 PM
NARRATIVE
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LPA Stephanie Rangel met with the infant center director Laurie Hauff, for a case management visit. LPA learned from research and interviews that the center did not submit an Unusual Incident Report (LIC 624) within seven days following the occurrence of an usual incident. The center also did not call an incident into CCL within 24 hours of the occurrence of the unusual incident.

As a result of this visit, deficiency is cited on the following page:

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 205-9167
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2016
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PRIMARY PLUS - CAMPBELL
FACILITY NUMBER: 430710231
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2016
Section Cited
101212(d)
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101212(d) Reporting Requirements. A report shall be made to the Department within 24 hours of the occurrence of any unusual incident as specified.

Licensee failed to report an unusual incident as required.
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LPA referred Licensee to Title 22 section 101212 (d) Reporting Requirements. Licensee to read section and submit a written statement stating she read and understands the regulation.
Licensee to also submit a completed Unusual Incident Report (LIC 624) to the Department by December 13, 2016.
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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: Timetra FaulconTELEPHONE: (408) 205-9167
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2016
LIC809 (FAS) - (06/04)
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