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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413380
Report Date: 10/02/2023
Date Signed: 10/02/2023 03:58:47 PM


Document Has Been Signed on 10/02/2023 03:58 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
SAN JOSE CC RO, 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: 7DATE:
10/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Maria FushikiTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Anna Morales conducted a Case Management inspection regarding an Unusual Incident that was reported by the facility to Licensing on 9/21/2023. LPA met with Licensee Maria Fushiki.

The incident occurred on September 20, 2023. LPA toured the inside and the outside of the day care, interviewed staff, and obtained a copy of children's roster and sign in/out sheet.

No deficiencies were cited during today's visit. Exit interview was conducted with Licensee Maria Fushiki.

Further investigation is required and the investigation is CONTINUING.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna MoralesTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
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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