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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411686
Report Date: 01/04/2023
Date Signed: 01/04/2023 01:45:15 PM


Document Has Been Signed on 01/04/2023 01:45 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: 8DATE:
01/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Shitei MiyagiTIME COMPLETED:
09:45 AM
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On 01/04/2023 at 8:30am, Licensing Program Analyst (LPA) Christina Uirbe conducted a visit to the facility for the purpose of a Case Management and met with licensee, Shitei Miyagi. Present at the time of the visit is 2 fingerprint cleared assistants and 8 day care children.

During the visit, LPA and licensee discussed making updates to the existing license. The licensee previously shared the duties of the Family Child Care Home with his wife, Yoko Miyagi. In March 2022, Yoko Miyagi passed away. The licensee has been informed that his wife's name will be removed from the license and Shitei will be the sole licensee.

Licensee stated that his adult daughter, Yurika MIyagi is possibly interested in being added to the licensee as co-licensee. In order to start this process, licensee is instructed to complete a new Application for Family Child Care License (LIC 279) form and choose the "Update" option and add Yuirila's name and submit the new license.

Licensee's daughter will need to complete a series of tasks in order to qualify as co-licensee which include, but are not limited to, completing the orientation, obtaining certificates for CPR/First Aid, Mandated Reporter, and Preventative Health & Safety Trainings, as well as other records.

Exit interview conducted and notice of site visit was given. Report was reviewed with the licensee, Shitei Miyagi.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
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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