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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411686
Report Date: 11/03/2022
Date Signed: 11/03/2022 01:41:50 PM


Document Has Been Signed on 11/03/2022 01:41 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:MIYAGI, YOKO & SHITEIFACILITY NUMBER:
434411686
ADMINISTRATOR:MIYAGI,YOKOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 440-6296
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94043
CAPACITY:14CENSUS: 10DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Shitei MiyagiTIME COMPLETED:
02:15 PM
NARRATIVE
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On 11/03/2022 at 11:15am Licensing Program Analyst (LPA) Christina Uribe, met with licensee Shitei Miyagi for an UNANNOUNCED ANNUAL INSPECTION. Present for the inspection were 10 daycare children and 2 fingerprint cleared assistants and 1 adult resident of home, and the licensee is within ratio today. Upon arrival LPA provided licensee a copy of the Entrance Checklist (LIC 126). The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday-Friday 830am-5:30pm.

The home is a single story home with 4 bedrooms, 2 bathrooms, living room, kitchen, dining area, garage and back yard. LPA observed the home to be neat and clean with central heating and ventilation for safety and comfort. All on/off-limit areas are consistent with the facility's pre-licensing reports.

The OFF-LIMIT AREAS are two back bedrooms, back bathroom, kitchen, and garage and are inaccessible to children by locked doors, safety gates and visual supervision.

The ON-LIMIT AREAS are the two front bedrooms, front bathroom, living room, dining area, & backyard.

The facility’s outdoor play space is located in the backyard of the home. The play structure, equipment, and fence are all in safe condition free from hazards which could pose a risk to children in care. There is ample shade available and gates are locked at all times while children are in the yard.

All hazardous materials and toxins are kept out of reach from children and are not accessible. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, carbon monoxide, telephone and fully stocked first aid kit. There are no pools, hot tubs or any other bodies of water present at the time of the inspection. Per licensee, there are no firearms on the premises or pets in the home.

The licensee completed the Health and Safety training, CPR/First Aid certification expires on 12/13/22. The licensee is in compliance with the immunization laws and has completed the mandated reporter for general training only.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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


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: 11/03/2022
NARRATIVE
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The licensee conducts and documents fire and disaster drills twice a year and the last conducted drill was on 08/11/22. All required forms are posted and visible for public review.

LPA Uribe reviewed 5 children’s files and personnel records. There is a current roster available for review. The facility does have liability insurance which is valid through 02/16/23. Staff interview also conducted and documented.



Incidental Medical Services (IMS) policy was discussed and the facility does not have any children with the need for medication to be kept at the facility at this time. 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.

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.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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. Licensee is advised to access this website and review all of the safe sleep regulations to meet compliance. 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.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
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: 11/03/2022
NARRATIVE
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Effective August 1, 2003 California Law requires Child Care Licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury Form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 business days.

See list below for deficiencies & technical violations cited during today's inspection. Additional information can be found on the attached deficiency & advisory note pages.

  • Type B Violation: Proof of TB clearance needed for two assistants. Proof of immunization for Measles (MMR) & Pertussis (Tdap) needed for one assistant.
  • Type B Violation: Criminal Record Statement (LIC 508) form needed for two assistants.
  • Type B Violation: Mandated Reporter Certificates needed for two assistants and licensee.
  • Technical Violation: Sleep logs needed for each 15-minute check on all infants under the age of 24 months (2 years).
  • Technical Violation: A copy of children's immunization record from their physician is needed for all children's files.
  • Technical Violation: Children who have finished eating or drinking must immediately be taken out of high chairs and booster seats.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Shitei Miyagi.

Page 3 of 3 ***End of Report***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 11/03/2022 01:41 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: MIYAGI, YOKO & SHITEI
FACILITY NUMBER: 434411686

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as two assistants and the licensee do not have a current certificate for Mandated Reporter Training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee and assistants will take the Child Care Provider (AB 1207) training at www.mandatedreporterca.com and obtain a certificate. Licensee will email LPA Uribe the certificates for all three persons to christina.uribe@dss.ca.gov no later than the due date of 12/02/22.
Type B
Section Cited
CCR
102416.1(a)(11)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (11) A signed statement regarding their criminal record history as required by Section 102370(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review , the licensee did not comply with the section cited above as two assistants do not have a signed Criminal Record Statement (LIC 508) form in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee will have these assistants sign the Criminal Record Statement (LIC 508) and email a scanned copy of these forms to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 12/02/22.

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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 11/03/2022 01:41 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: MIYAGI, YOKO & SHITEI
FACILITY NUMBER: 434411686

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as two assistants do not have proof of TB clearance and one assistant does not have proof of immunity to Measles (MMR) & Pertussis (Tdap) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee will have both assistants obtain a TB clearance and one assistant obtain proof of immization for Measles (MMR) & Pertussis (Tdap). Licensee will email a scanned copy of these records to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 12/02/22.
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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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