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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413380
Report Date: 12/13/2019
Date Signed: 12/13/2019 12:56:39 PM

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:FUSHIKI, MARIAFACILITY NUMBER:
434413380
ADMINISTRATOR:FUSHIKI, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 390-3435
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:14CENSUS: 9DATE:
12/13/2019
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Maria FushikiTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuoc Doan conducted an unannounced Annual Inspection of the Family Day Care home. LPA met with Assistant Providers Irma Bastidas and Rosa Gomez and was informed that Licensee is currently out of town. LPA informed Assistant Providers the purpose of the inspection and spoke to Licensee over the telephone. Present were nine children in care, of whom three were under two years old.

The home’s operating days and hours are Monday through Friday from 08:00 AM to 05:30 PM. The home maintains telephone service. The License and Notification of Parents’ Rights were observed to be posted. The home was inspected inside and out with Irma Bastidas. The home was clean and orderly, with heating and ventilation for the safety and comfort of children in care. The observed children’s toys, play equipment, and furniture were in good condition. There were no baby walkers at the day care. Restroom used by children was clean and in operating condition.

Areas used for day care are the Dining Room, Family Room, and a restroom in the Family Room on the first floor. The whole second floor is Off Limits to the children and LPA observed a child safety gate installed at the base of the staircase to prevent access. Backyard is fenced and is used for outdoor activity. LPA observed outdoor toys and equipment. The home no longer has a swimming pool. LPA observed the trampoline area in backyard was enclosed with fencing to keep it inaccessible to children. Licensee and Assistant Provider Irma Bastidas stated that day care children do not use the trampoline. There were no bodies of water observed. L

Licensee stated that there were no weapons such as firearms stored on the premises. A fully charged fire extinguisher was observed. Smoke and Carbon Monoxide Detectors were tested and proved to be functioning. Licensee stated that the day care does not provide transportation to day care children. The home has two pet dogs and one cat that are kept away from children.

LPA reviewed the roster of children in care and obtained a copy.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2019
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 4
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: FUSHIKI, MARIA
FACILITY NUMBER: 434413380
VISIT DATE: 12/13/2019
NARRATIVE
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Children’s files were reviewed, which included records of Identification and Emergency Information, Consent for Emergency Medical Treatment, Receipt for Parents' Rights Notice, Immunization, and form LIC9224.. Licensee and Assistant Providers Irma Bastidas and Rosa Gomez's files were reviewed, which included TB clearance, form LIC 9108, form LIC 9052, immunization record for Measles and Pertussis, and required Training. Both Assistant Providers' Pediatric CPR/1st Aid Certification expires 02/15/21.

Licensee stated that Adult over the age of 18 and reside in the home are Licensee, Licensee's spouse and Daughter, and two renters. They have obtained clearance for Criminal Background and Child Abuse Index Checks and Tuberculosis.

Facility is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Regulations, Online option to pay Annual License fee, Adoption of new Laws, etc.
Beginning January 1, 2019 AB2370 requires licensed homes to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” and Safe Sleep information to facility.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. The following information regarding ADA was provided: US Department of Justice (USDOJ) 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.

In the areas that were evaluated, regulatory violations were observed at the time of the inspection. Exit Interview was conducted, where this report, the violations, plan of corrections, and appeal rights were reviewed with Assistant Provider Irma Bastidas. LPA also spoke to Licensee about the violations and plan of corrections over the telephone.

A copy of this report and the appeal rights were provided to facility when the inspection concluded.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: FUSHIKI, MARIA
FACILITY NUMBER: 434413380
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2020
Section Cited

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OPERATION OF A FAMILY CHILD CARE HOME. Each family child care home shall conduct fire drills and disaster drills at least once every six months. The licensee shall document the drills [...].
This requirement is not met as evidenced by:
Licensee failed to provide document
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showing record of fire and disaster drills practiced with the children within the last 6 months. The last documented drill was conducted on 05/07/19. This poses a potential risk to the health and safety of children in care.
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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: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: FUSHIKI, MARIA
FACILITY NUMBER: 434413380
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2020
Section Cited

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HEALTH & SAFETY CODE. [...] the licensee shall provide to the parents or legal guardians of the newly enrolling child copies of any licensing report that the licensee has received during the prior 12-month period that documents any Type A citation [...] [and] pertains to a conference conducted by a local licensing agency. [...] The licensee shall keep
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verification of receipt in each child's file.
This requirement is not met as evidenced by:
Per LPA's review of children's files, Licensee failed to show that Child 1 and Child 2 have verification of receipt of a copy of the Licensing reports dated 02/06/19 and 05/16/19. This poses a potential risk.
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Type B
01/03/2020
Section Cited

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HEALTH & SAFETY CODE: Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent [...], and the name and telephone number of the child's physician.
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Based on LPA's review of the roster and files for children in care, Child 1 and 2 are present during LPA's inspection but are not listed on the roster. This poses a potential risk to the health and safety of the children in care.
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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: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4