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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411432
Report Date: 09/29/2021
Date Signed: 09/29/2021 11:30:40 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: 4DATE:
09/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Yumiko MatsuiTIME COMPLETED:
11:45 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
#2 Licensing Program Analysts (LPAs), Marilou Monico and Aman Sharma, made an unannounced Required - 1 Year inspection. Present in the home were Licensee, Yumiko Matsui, Licensee, Hiroshi Matsui, and four preschool age children. LPAs explained with Yumiko the purpose of today's visit. Yumiko and Hiroshi are the adults residing in the home. The daycare is open Monday to Friday from 9:00 AM to 5:00 PM. The daycare is a 3-bedroom, 2-bath house.

LPAs toured the home inside and out. 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. LPA observed sufficient toys and play equipment for the day care children. Bathroom used by children was observed to be clean and in good condition. There were no bodies of water observed. Yumiko states that there are no weapons in the home. LPAs observed a fully charged 3A40BC fire extinguisher, functioning carbon monoxide and smoke detector, covered fireplace, and fenced backyard. Cleaning compounds, sharp objects, and other similar items were stored inaccessible to children.

LPA discussed with Licensee Assembly Bill (AB) 1207 (Mandated Child Abuse Reporter Training) which is required training that began on January 1, 2018 and requires renewal every two years. Mandated Reported Training can be accessed at www.mandatedreporterca.com. Yumiko's Mandated Reporter Training expires on November 15, 2022 and her Pediatric CPR/First Aid certification has an expiration date of September 28, 2023. AB 633 was also discussed with Yumiko.

LPAs reviewed four children's files and six helper's files. Copy of children's roster was obtained. LPAs observed that fire/disaster drill was conducted on June 04, 2021.

Continuation on next pages:
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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 3
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: 09/29/2021
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
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 exemptions. LPAs reminded Yumiko of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

LPAs reviewed with Yumiko the violations that would result in an immediate assessment of civil penalty in the amount of $500. Yumiko is encouraged to visit the Department’s website at www.cdss.ca.gov [Shortcut: www.ccld.ca.gov] to access resources for Providers, Regulations, Adoptions of new laws, pay annual fees etc.
LPA reviewed with Yumiko and provided her a copy of Safe Sleep Regulations (PIN 20-24-CCP). Incidental Medical Services (IMS) policy was discussed.

As a result of this inspection, deficiencies were cited on the following page:

A 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: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2021
Section Cited

1
2
3
4
5
6
7
On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Per review of records, Helpers H-1 thru H-6 have expired Mandated Reporter Training. This poses a potential risk to the health and safety of children in care.
8
9
10
11
12
13
14
Type B
10/29/2021
Section Cited

1
2
3
4
5
6
7
Commencing September 1, 2016, 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Per review of records, Helpers H-4 and H-5 are missing immunization in measles, pertussis, and influenza. H-6 is missing measles and influenza. This poses a potential risk to the health and safety of children in care.
8
9
10
11
12
13
14
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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3