013423319-5-5-2022-02-CC-ILOA-CE5RDZ-20220505125648

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013423319
Report Date: 05/05/2022
Date Signed: 05/05/2022 12:56:57 PM

Document Has Been Signed on 05/05/2022 12:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME:	TOYOZUMI, YUKI		FACILITY NUMBER:	013423319
ADMINISTRATOR:	TOYOZUMI, YUKI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 213-3441
CITY:	BERKELEY	STATE: CA	ZIP CODE:	94705
CAPACITY:	14	CENSUS: 0	DATE:	05/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:53 AM
MET WITH:	Yuki Toyozumi and Keiko Ohara		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/5/2022 at 9:53 am, Licensing Program Analyst (LPAs) Indira Loza met with Licensees Yuki Toyozumi for an Unannounced Required Annual Inspection. Present during the inspection were the Licensees and two business partners, Keiko Ohara and Yukie Chan, There were no children in care. Licensee’s home was toured for a health and safety inspection. The facility operates from 2:30pm - 5:45pm on Mondays, Tuesdays, Thursdays, and Fridays, and from 2pm - 5:45pm on Wednesdays. The home is two stories with 4 bedrooms, and 3 bathrooms, the house is clean and has heating and ventilation for the safety and comfort of children in care. The on limit areas are room to the left of the entry door, the dining room, and the downstairs bathroom. The kitchen and dining room are temporarily off limits. The off limit areas are the entire upper level of the home, the office downstairs on the right to the bathroom, and the backyard which is kept off limits with closed doors and/or visual supervision. The dining room will used as the isolation area. LPA Loza observed an ample supply of educational activities, which appear to be age appropriate and in good condition. LPA did not observe any bodies of water, hazardous items or toxins accessible today. The home has a fully charged 2A40BC fire extinguisher, working smoke detector, carbon monoxide detector, and working telephone. The fire alarm is a pull down alarm system. The licensee stated that there are no firearms in the home. The licensee and assistants had current CPR and Mandated reporter certificates. All the children's files were reviewed. All required forms are posted and visible for public view. LPA obtained the facility roster. LPA observed a current fire and disaster drill log with the last drill conducted on 3/18/22. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) *************809 Continued*****************

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira Loza	TELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: TOYOZUMI, YUKI	FACILITY NUMBER: 013423319
	VISIT DATE: 05/05/2022

NARRATIVE

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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. The licensees stated that there is one child in care that may require medication while in care.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

There are no deficiencies being cited today.
A Notice of Site visit was given to Licensee, and Licensee was reminded that it is required to be posted for 30 days.
An exit interview was conducted with the Licensee.

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira Loza	TELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

LIC809 (FAS) - (06/04)

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