Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710231
Report Date: 04/05/2017
Date Signed 04/05/2017 02:10:16 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: 62DATE:
04/05/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Laurie HauffTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Rangel, conducted an unannounced random visit to the Facility today. LPA met with director Laurie Hauff and explained the nature of today's visit to her. LPA toured the Facility both inside and outside during today's visit. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), Menus, and Activity Schedule.

LPA reminded director of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violations within a 12 month period.

LPA reviewed 10 children's and 6 staff files during today's visit. Each child's file reviewed contains emergency information. The staff files reviewed contain the required transcripts/verification of experience. Director has current CPR and First Aid certifications on file with an expiration date of 10/23/17. Director understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips).

LPA observed that the teacher/child ratio was in compliance during today's visit. Director understands the conditions, limitations, and capacity specifications of the Facility license. Director understands that children shall be visually supervised at all times.

LPA observed that all rooms are clean and safe for all children and staff. LPA observed solid waste containers with tight-fitting lids throughout the Facility. The classroom is clean, sanitary, and operable. Director states that there are no weapons or firearms on the premises. The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. All food and beverages that require refrigeration are stored in covered containers.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 205-9167
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2017
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
VISIT DATE: 04/05/2017
NARRATIVE
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Each infant has personal items individually stored and labeled. Infant Needs and Service Plan are up to date. Cleaning supplies are stored away from children. Medication(s) at the facility will be stored in the nurse's office. Each room has a working carbon monoxide and smoke detector.

LPA observed all furniture and equipment is in good condition and safe for the children. The playground area utilized by toddler children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. Drinking water is readily available for the toddler children in the outdoor playground area. Personal sippy cups and pitchers/disposable cups are available for the toddler children. LPA observed that the outdoor equipment is age appropriate and in good condition. There is sufficient resilient materials in the outdoor playground area. LPA did not observe any bodies of water.

LPA discussed the requirements of AB 633. Acknowledgement of Receipt of Licensing Reports (LIC 9224) and licensee understand the requirements. All staff reviewed have needed immunization's per SB 792.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Licensing Forms, Title 22 Regulations and information can be obtained through the internet at
www.ccld.ca.gov.

Deficiency cited on the following page.

Appeal rights printed and reviewed with director.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, 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: 04/05/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2017
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: 04/05/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2017
Section Cited
101770(e)(2)
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Criminal Record Clearance. Prior to working or volunteering in a licensed child care facility, all individuals subject to a criminal record review shall request a transfer of a criminal record clearance from another facility or Trustline. LPA observed that one staff member is cleared but not associated to the infant program at the preschool. $500 civil penalty assessed during today's visit
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Site Director stated that she will immediately fax in the criminal record transfer request (LIC 9182) with current government issued ID to CCL to associate the teacher.
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AB633 Parent Notification is required.
This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.
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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: 04/05/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2017
LIC809 (FAS) - (06/04)
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