Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710231
Report Date: 04/20/2017
Date Signed 04/20/2017 12:25:24 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: 57DATE:
04/20/2017
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Laurie HauffTIME COMPLETED:
12:45 PM
NARRATIVE
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LPA Stephanie Rangel met with director Laurie Hauff for a case management visit. LPA learned from interviews that an unusual incident report (LIC 627) was not submitted to CCL regarding a complaint allegation that was substantiated on 4/5/17. The allegation was that staff handled child in a physically inappropriate manner and the result was that the teacher was terminated.

As a result of this visit, deficiencies are cited on the following page:

Appeal rights were printed and reviewed with director.

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: 04/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2017
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2017
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.

LPA earned that an unusual incident report nor a phone call was made to CCL for the complaint alligation made on 3/30/17.
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Director stated that she will submit an unusal incident report for the alligation to CCL by 4/21/17.

Director needs to submit a written plan to CCL indicating the understanding of the regulation and how to prevent the deficiency in the future by 4/21/2017.
Civil penalty was assessed.
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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: 04/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2017
LIC809 (FAS) - (06/04)
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