<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411432
Report Date: 10/16/2019
Date Signed: 10/16/2019 10:33:19 AM

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:MATSUI, HIROSHI & YUMIKOFACILITY NUMBER:
434411432
ADMINISTRATOR:MATSUI, HIROSHI & YUMIKOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 517-0919
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:14CENSUS: 12DATE:
10/16/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Yumiko MatsuiTIME COMPLETED:
10:40 AM
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
Licensing Program Analyst (LPA), Marilou Monico, made an unannounced annual random inspection. LPA met with Licensee, Yumiko Matsui, and explained the purpose of today's inspection. Also present in the home were two adult helpers and 12 preschool age children. The daycare is open Monday to Friday from 9:00 AM to 5:00 PM. There are two adults living in the home: Licensees, Yumiko and Hiroshi.

The indoor and outdoor areas were inspected. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean and orderly. There is a fully charged 3A40BC fire extinguisher, working smoke and carbon monoxide detector, barricaded fireplace, and no bodies of water. Off limit areas in the home: 3 bedrooms, 1 bathroom, kitchen, and garage. Off limit areas outside the home: right side section of the backyard and storage shed. Cleaning products, sharp objects, and other similar items are stored inaccessible to children. Per licensee, there are no weapons in the home. Ten children's files and two helpers' files were reviewed. Licensee and her two helpers have completed the Mandated Reporter Training. LPA reminded licensee that Mandated Reporter Training requires renewal every two years from completion date. Licensee maintains a current children's roster and fire drill log. LPA obtained copies of children's roster. Licensee and her two adult helpers have current CPR/First Aid certifications. The home has a working telephone which is (408) 517-0919.

LPA advised licensee that beginning January 1, 2019, Assembly Bill (AB) 2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility.


(REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 10/16/19):
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019
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 2
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: MATSUI, HIROSHI & YUMIKO
FACILITY NUMBER: 434411432
VISIT DATE: 10/16/2019
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
26
27
28
29
30
31
32
(CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 10/16/19):

A review of staff records during today's inspection indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemption.

Incidental Medical Services (IMS) policy was discussed. Licensee states none of the children is using any medications. LPA reminded licensee that when any IMS is provided, a Plan for Providing IMS must be submitted to the Department.

As a result of this inspection, there were no deficiencies cited.


NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2