Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430710231
Report Date: 04/20/2017
Date Signed 04/20/2017 12:32:11 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
04/11/2017 and conducted by Evaluator Stephanie C Rangel
COMPLAINT CONTROL NUMBER: 07-CC-20170411163808
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
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Laurie HauffTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff failed to provide a copy of type A citation
INVESTIGATION FINDINGS:
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A visit was conducted by Licensing Program Analyst (LPA), Stephanie Rangel. LPA met with director Laurie Hauff and discussed the above allegation. LPA toured the facility both indoor and out and reviewed children's files. Based on LPA interviews and a review of children's records 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: 04/20/2017
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.
LIC9099 (FAS) - (06/04)
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Control Number 07-CC-20170411163808

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: 04/20/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/04/2017
Section Cited
1596.8595c
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Health and Safety Code Section 1596.8595 (c) A licensed child care home shall provide to the parents of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal
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Licensee to review this section and submit written statement indicating what she will do to prevent this from occurring again in the future.

Licensee to provide copies of Acknowledgement of Receipt of Licensing Report (LIC9224) signed by an authorized representative from the site visit documenting a "Type A" citations.
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rights of children in care as specified in paragraph (1) of subdivision (a) of Section 1596.893b.

LPA viewed three children files that did not include the LIC 9224 issued on 4/5/17, who were present in the facility after the deficiencies on the report were cited.
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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
LIC9099 (FAS) - (06/04)
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