Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430710231
Report Date: 04/05/2017
Date Signed 04/05/2017 01:49:30 PM


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/30/2017 and conducted by Evaluator Stephanie C Rangel
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20170330132418
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
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Laurie HauffTIME COMPLETED:
11:29 AM
ALLEGATION(S):
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Staff handled child in a physically inappropriate manner
INVESTIGATION FINDINGS:
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A visit was conducted by Licensing Program Analyst (LPA), Stephanie Rangel. LPA met with site director Jenna Fennel and director Laurie Hauff and discussed the above allegation. LPA toured the facility both indoor and out and conducted interviews with staff. Based on LPA interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.”)

Deficienciency cited on the following page:

Appeal rights were printed and reviewed.

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
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Control Number 07-CC-20170330132418

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
101223(a)(1)
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Personal Rights. Each child shall be accorded dignity in his/her personal relationships with staff, and other persons.
LPA learned that children's personal rights were violated when they were picked up with one arm and not spoken to with a positive gentle attititude by one staff member.
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Primary Plus terminated the staff person.
Analyst requested a written plan of correction to train all staff on discipline policies and children's personal rights. Copies of training should be submitted to analyst by 04/30/2017.
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THIS REPORT MUST BE GIVEN TO ALL CURRENT AND FUTURE PARENTS AND THEY NEED TO SIGN LIC 9224 FOR ONE YEAR FROM TODAY'S DATE.
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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
LIC9099 (FAS) - (06/04)
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