434411686-1-16-2020-52-CC-JSAR-BKVQWS-20200116113225

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434411686
Report Date: 01/16/2020
Date Signed: 01/16/2020 11:32:33 AM

COMPREHENSIVE INSPECTION

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 STE 1102
OAKLAND, CA 94612

FACILITY NAME:	MIYAGI, YOKO & SHITEI		FACILITY NUMBER:	434411686
ADMINISTRATOR:	MIYAGI,YOKO		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 621-0276
CITY:	MOUNTAIN VIEW	STATE: CA	ZIP CODE:	94043
CAPACITY:	14	CENSUS: 8	DATE:	01/16/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Shimon Miyagi		TIME COMPLETED:	11:15 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	I, Licensing Program Analyst (LPA), James Sampair, made an annual random inspection of the facility that began at 8:30 am. The Licensees, Yoko and Shitei Miyagi, were not present at the time of the inspection. The Licensees live in the home with their adult son who works there and was interviewed, Shimon Miyagi, because he was in charge at the time. Also present was 1 other employee, Takako Yanase. Under care at the time of the inspection were a total of 8 children: 1 infant and 7 toddlers. All the adults meet the criminal background clearance requirement. The areas used for the childcare are the dining room, the living room, bedroom 2, and bedroom 1 (used only for storage at the time of the inspection), the front bathroom, and the back yard. the off-limits areas of the home include the 2 bedrooms and 1 bathroom in the back of the home, and the garage. The facility had a working smoke detector, carbon monoxide detector, and fully recharged size 3A10BC fire extinguisher. There were no bodies of water. The home is kept clean and orderly, with heating and ventilation for safety and comfort. The home has safe toys, play equipment, and materials. The Licensees were not present in the home, though Shimon Miyagi ensured that children are supervised at all times by the Licensees and/or an assistant. When temporarily away, the Licensee arranges for a substitute adult to care for the children. The Licensees maintain the capacity on the license. Each child has safe, comfortable, and healthy accommodations, furnishings, and equipment. Shimon Miyagi had current pediatric CPR and first aid certificates. Shimon Miyagi stated there were no guns or weapons in the home. Licensees have no pets. At 9:05 am, 6 children's file were reviewed and found to be complete with immunization records.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2020

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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: MIYAGI, YOKO & SHITEI	FACILITY NUMBER: 434411686
	VISIT DATE: 01/16/2020

NARRATIVE

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Licensees rent the facility and has consent from the owner of the facility for its use as a child care facility. The Licensee is utilizing the child care roster. Shimon Miyagi was reminded that anyone working, residing or frequently visiting the home must be fingerprint-cleared prior to being in the presence of children, or an immediate civil penalty can be assessed. Also discussed were documents to be provided to parents and legal guardians and Safe Sleep. Incidental Medical Services (IMS) policy was discussed. 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 (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. Please register your email address at childcareadvocatesprogram@dss.ca.gov for all new licensing updates. The Licensees completed the mandated reporter training.

There were no deficiencies cited in today's visit. An exit interview was conducted with the Licensee. Appeal rights were given to the Licensee.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2020

LIC809 (FAS) - (06/04)

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