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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313146
Report Date: 04/17/2023
Date Signed: 04/17/2023 12:49:04 PM


Document Has Been Signed on 04/17/2023 12:49 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:NAKAMURA, NORIKOFACILITY NUMBER:
304313146
ADMINISTRATOR:NAKAMURA, NORIKOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 331-3219
CITY:IRVINESTATE: CAZIP CODE:
92614
CAPACITY:14CENSUS: 9DATE:
04/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee, Noriko NakamuraTIME COMPLETED:
01:00 PM
NARRATIVE
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An Annual Random inspection was conducted at the facility by Licensing Program Analysts (LPA) Dianna Valdez Santana and Giselle Lucero met with licensee, Noriko Nakamura census was taken. There were 9 children, 4 infants and 5 preschool children in care. Licensee was operating within the licensed capacity as specified on license.

A review of the Facility Personnel Report Summary on this date, 04/13/23 indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are 2 adults including the licensee and one minor living in the facility. Facility Day care hours are 8:00am- 6:00pm, Monday through Friday.

During today’s inspection, LPAs and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas are made inaccessible by means of locked doors and child safety gates. The childcare area consists of the living room, dining room and one restroom. The outside backyard is currently an off limit area and the staff walk the children to the nearby playground. The children walk through the living/dining room to the bathroom. Licensee stated the children's primary area is the living room and dining room. There are working carbon monoxide, smoke detector alarms in the home that meet statutory and State Fire Marshall standards. The fire extinguisher was expired and licensee stated she will purchase a new one. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. There is a fireplace in the living room covered by a wooden cover to ensure it is inaccessible to children in care. The home has age-appropriate toys for the ages served. LPAs verified there is a working telephone service, which is the licensee’s cellphone. Licensee stated they use the playground nearby as their outdoor play area. There were no poisons or other items observed which could pose a danger to children. There are no bodies of water on the premises. Page 1 of 4.

SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8


Document Has Been Signed on 04/17/2023 12:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: NAKAMURA, NORIKO
FACILITY NUMBER: 304313146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(d)(1)
Operation of A Family Child Care Home
(d) The home shall provide safe toys, play equipment and materials. (1) Fixtures, furniture, and equipment that have been banned or recalled by the United States Consumer Product Safety Commission shall not be used for children in care or accessible to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 4 infants were in a baby bouncer/jumprer. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2023
Plan of Correction
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Licensee immediately removed the bouncer/jumper from the daycare area.
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above, the fire extinguisher was expired and had not been served. Having an expired fire extinguisher poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Licensee will service or purchase a new fire extinguisher and send LPA Valdez Santana a picture via email at dianna.valdezsantana@dss.ca.gov
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: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8


Document Has Been Signed on 04/17/2023 12:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: NAKAMURA, NORIKO
FACILITY NUMBER: 304313146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews, and record review, the licensee did not comply with the section cited above in the licensee did not document their earthquake and fire drills which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Licensee will email LPA proof of her eathquake/fire drill log at dianna.valdezsantana@dss.ca.gov
Type B
Section Cited
CCR
102425(a)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation abd interviews, the licensee did not comply with the section cited above in 4 out of 4 infants did not have a play yard/crib to sleep in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2023
Plan of Correction
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Licensee will send LPA Valdez Santana a picture of the 4 playards for each infant.
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: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8


Document Has Been Signed on 04/17/2023 12:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: NAKAMURA, NORIKO
FACILITY NUMBER: 304313146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 4 out of 4 infants did not have a 15 minute sleeping log. Licensee was not documenting her observations while they slept which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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LPA provided Licensee a 15 minute log template, licensee will begin documenting the infants sleeping as of today and will send LPA 2 weeks worth of sleep logs via email at dianna.valdezsantana@dss.ca.gov
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 3 out of 9 children did not have proof of immunizations in their files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Licensee will email LPA 3 children's proof of immunizations at dianna.valdezsantana@dss.ca.gov
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: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 04/17/2023 12:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: NAKAMURA, NORIKO
FACILITY NUMBER: 304313146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 1 infants under 12 months of age did not have the infant sleeping plan form in their file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Licensee will email LPA a copy of the completed and signed infant sleeping plan form at dianna.valdezsantana@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
LIC809 (FAS) - (06/04)
Page: 5 of 8


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: NAKAMURA, NORIKO
FACILITY NUMBER: 304313146
VISIT DATE: 04/17/2023
NARRATIVE
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The licensee has a current roster of children in care. Children’s records for children present during LPAs’ inspection were reviewed. LPA reviewed 5 children’s files. LPAs reviewed LIC 9227 Individual Infant Sleeping Plan forms with licensee. The licensee’s Pediatric CPR/First Aid certification is current and expires 11/2023.

Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee and assistant were reviewed and within compliance.

During today’s inspection, while LPAs were reviewing staff files, LPAs observed licensee and her two assistants did not have Mandated Reporter training certificates. The training is not offered in Japanese so they are exempt from the training. Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years.

Incidental Medical Services (IMS) policy was discussed and licensee stated she is not currently administering medication. 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) 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 licensee understands she must be present in the facility, must ensure children in care are supervised at all times, and children are not to be left in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunization's, Pediatric CPR/First Aid, and mandated reporter training.



CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. Page 2 of 4.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC809 (FAS) - (06/04)
Page: 8 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: NAKAMURA, NORIKO
FACILITY NUMBER: 304313146
VISIT DATE: 04/17/2023
NARRATIVE
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx

NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

· Always place infants on their backs for sleeping


· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold.

Safe sleep consultation provided during today's inspection. Safe sleep 15-minute log for infant present reviewed during today's consultation. LPA Valdez Santana asked Licensee if she had any questions or concerns about Infant Safe Sleep regulations 102425. A review of this regulation was provided to Licensee.

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SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC809 (FAS) - (06/04)
Page: 7 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: NAKAMURA, NORIKO
FACILITY NUMBER: 304313146
VISIT DATE: 04/17/2023
NARRATIVE
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Based on LPAs’ observations, licensee had a 10 month old infant in a baby bouncer, which are banned in all child care centers and day care home. The following violation was observed and is being cited: CCR Section102417(d)(1), see attached LIC 809D.

In the areas that were evaluated, 7 Type B deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

Deficiencies observed are Physical Plant - Type B: 102425(c) Infant Safe Sleep, 102417(g)(1) Operation of A family child care home, 102417 (d)(1) Operation of A Family Child Care Home, 102425(a) Infant Safe Sleep, 102417 (g)(9)(A) Operation Of A Family Child Care Home, 102425 (j)(2) Infant Safe Sleep, 102418 (g) Immunizations.


Exit interview conducted and report was reviewed with the licensee, Noriko Nakamuri. Appeal Rights and were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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.

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SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8