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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411432
Report Date: 12/18/2024
Date Signed: 12/18/2024 11:34:48 AM

Document Has Been Signed on 12/18/2024 11:34 AM - 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MATSUI, HIROSHI & YUMIKOFACILITY NUMBER:
434411432
ADMINISTRATOR/
DIRECTOR:		MATSUI, HIROSHI & YUMIKOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 517-0919
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 14TOTAL ENROLLED CHILDREN: 49CENSUS: 10DATE:
12/18/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:24 AM
MET WITH:Hiroshi Matsui & Yumiko MatsuiTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On December 18, 2024 at 9:24 AM, Licensing Program Analyst (LPA), Marilou Monico, made an unannounced Annual Random inspection. LPA met with Licensee, Hiroshi Matsui, and explained to him the nature of today's inspection. Hiroshi stated that his wife, Yumiko, is out for medical appointment but will be back soon. Also present in the home were two adult assistants (S1 & S2) and 10 children: 1 infant and 9 preschool age. All required posting materials were posted. The daycare is open Monday thru Friday from 9:00 AM to 5:00 PM. There are no active waivers or exceptions for this facility. Licensee, Yumiko Matsui, arrived during the inspection. Both licensees are the adults residing in the home.

LPA obtained a copy of current children's roster. Fire/disaster drill was completed on November 10, 2024. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke and carbon monoxide detectors, and covered fireplace. Yumiko stated that there are no weapons or firearms in the home.

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 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

Licensee, Yumiko Matsui, was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.
Continuation on next pages:
Joel SeguraTELEPHONE: (408) 334-8550
Marilou MonicoTELEPHONE: (408) 334-8549
DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MATSUI, HIROSHI & YUMIKO
FACILITY NUMBER: 434411432
VISIT DATE: 12/18/2024
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Off limit areas inside the home: 3 bedrooms, 1 bathroom, kitchen, and garage. LPA observed that the home is clean and orderly. Cleaning products, sharp objects, and other items that are dangerous to children were stored inaccessible. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. The children's bathroom is clean, sanitary, and operable. Off limit areas outside the home: right side yard and locked storage shed located on the left section of the home. There were no bodies of water observed.

LPA reviewed 10 children's files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization Records. Licensee carries daycare insurance.

LPA reviewed two helper's files(S1 & S2) for the following records: Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), immunizations, and TB test. Both licensees have immunizations in measles, pertussis and flu, current Pediatric CPR/First Aid certifications, and Mandated Reporter training. LPA reminded Yumiko that Mandated Reporter training must be renewed by all staff every 2 years.

LPA discussed the safe sleep regulations with Yumiko 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 Yumiko 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.

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.

Continuation on next page:
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MATSUI, HIROSHI & YUMIKO
FACILITY NUMBER: 434411432
VISIT DATE: 12/18/2024
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Licensee, Yumiko Matsui, was informed of the MyChildCarePlan.org site; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&R's) throughout California.

There were no deficiencies cited.

Exit interview conducted and the report was reviewed with Yumiko Matsui, Licensee.

During the exit interview, the Licensee, Yumiko Matsui, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC809 (FAS) - (06/04)
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