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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413506
Report Date: 06/12/2025
Date Signed: 06/13/2025 11:47:02 AM

Document Has Been Signed on 06/13/2025 11:47 AM - 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:NISHIYAMATO ACADEMY PRESCHOOL, SAN JOSEFACILITY NUMBER:
434413506
ADMINISTRATOR/
DIRECTOR:		TOMOMI KUSUYAMAFACILITY TYPE:
850
ADDRESS:52 HAROLD AVENUETELEPHONE:
(408) 243-1174
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY: 66TOTAL ENROLLED CHILDREN: 39CENSUS: 36DATE:
06/12/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:52 AM
MET WITH:Tomomi KusuyamaTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst(LPA) Mandeep Kaur met with Director, Tomomi Kusuyama, for an unannounced Annual/Random inspection. The purpose of today's inspection was explained with Director. Facility's License, Notification of Parents’ Right Poster, Child Car Seat Law, Personal Rights (LIC 613A), Emergency Disaster Plan, Menus, Activity Schedule, and Earthquake Preparedness Checklist were observed to be posted. The preschool program has a active waivers: outdoor space. The center's operating hours are Monday through Friday from 08:30AM to 3:30 PM. The facility is licensed to serve children ages 2.5 years to entry into kindergarten in Rooms 1,2,3 and 4.

LPA toured the indoor and outdoor areas. LPA observed that two teacher aid present in room 2 with chidlren. Director was advised of having a qualified teacher present in the classroom. Fire drill was conducted on May 14,2025. The facility has current children's roster and a copy was provided to LPA during the inspection. LPA observed cleaning supplies to be accessible to the children in rooms : 1, 2, 3 and 4. Director removed the cleaning supplies and placed inaccessible area to the children. Furniture and equipment were observed to be age appropriate and in good condition. The bathrooms for children and staff are clean, sanitary, and operable. Director stated that staff clean the facility on daily basis.

Director stated that children bring food from home. Drinking water is available for the children indoor individual water bottles. LPA observed trash cans with tight fitting covers for the disposable of solid waste.
The facility has fire extinguishers and working smoke and carbon monoxide detectors.

Continuation on next pages:
Belinda Devall
Mandeep Kaur
DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2025
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/13/2025 11:47 AM - It Cannot Be Edited


Created By: Mandeep Kaur On 06/12/2025 at 11:04 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: NISHIYAMATO ACADEMY PRESCHOOL, SAN JOSE
FACILITY NUMBER: 434413506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2025

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 records review, the licensee did not comply with the section cited above in 2 staff (S1&S2) out of 5 staff do not have current Mandated reporter Training (AB1207) certificate on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2025
Plan of Correction
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By plan of correction due date, 06/26/2025, Licensee will submit the copy of Mandated Reporter Training(AB1207) certificates for Staff(S1&S2) to the department.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center 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. Staff (S3) does not of proof of Measles on file and Staff (S4) does not have immunizations records( influenza, pertussis, and measles) on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2025
Plan of Correction
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By Plan of corection due date 06/26/2025, licensee will submit the copy of proof of Measles for Staff (S3) and immunizations records influenza, pertussis, and measles) for Staff (S4) to the department.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Belinda Devall
NAME OF LICENSING PROGRAM MANAGER:
Mandeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/13/2025 11:47 AM - It Cannot Be Edited


Created By: Mandeep Kaur On 06/12/2025 at 11:04 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: NISHIYAMATO ACADEMY PRESCHOOL, SAN JOSE
FACILITY NUMBER: 434413506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216.1(b)(1)
Teacher Qualifications and Duties
(b) Prior to employment, a teacher shall meet the requirements of (b)(1) or (b)(2) below: (1) A teacher shall have completed, with passing grades, at least six postsecondary semester or equivalent quarter units of the education requirement specified in (c)(1) below; or shall have obtained a Child Development Assistant Permit issued by the California Commission on Teacher Credentialing.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, interview and records review, the licensee did not comply with the section cited above. LPA observed two staff (S3 &S6) are teacher aid, present with children in Room 2. Director, Tomomi Kusuyama stated that for Staff (S3), the degree is from Japan and has not been evaluated within the Unites states of America and Staff(S6) is a teacher aid in room 2, which posesa potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2025
Plan of Correction
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By plan of correction due date, 06/26/2025, Licensee will submit the written statement of understanding of Title 22 required regualtions for teacher qualifications and submit the evaluated transcripts/degree of staff (S3). Director stated that she is going to be present in Room 2 with children.
Type B
Section Cited
CCR
101238(g)
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in Rooms 1,2,3, and 4 accessible to the children, which poses a potential health, safety or personal rights risk to persons in care. LPA observed a ant killer spray bottle including the cleaning supplies in Room 2 accessible to the children.
POC Due Date: 06/12/2025
Plan of Correction
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Deficieny was cleared during today's inspection. Director removed all the cleanig supplies and ant killer spray bottle to the inaccessible areas of the children.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Belinda Devall
NAME OF LICENSING PROGRAM MANAGER:
Mandeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2025


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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: NISHIYAMATO ACADEMY PRESCHOOL, SAN JOSE
FACILITY NUMBER: 434413506
VISIT DATE: 06/12/2025
NARRATIVE
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The playground is surrounded with appropriate fencing and the outdoor surfaces are safe. Shade is provided by canopies. Drinking water is readily available for the children outdoor via individual water
bottles. LPA observed climbing structures with resilient material under and around the structures. There were no bodies of water observed. Director stated that there are no weapons or firearms on the premises.

LPA reviewed 5 random children's files. Children records reviewed include Admission Agreement, Identification and Emergency Information, Consent for Emergency Medical Treatment, Physician's Report, TB test, Immunizations, Parent Right's Receipt, Personal Rights, and Health History.

LPA reviewed 5 staff files. Staff records reviewed include Employee Rights, Statement Acknowledging
Requirement to Report Child Abuse, Health Screening Report with TB Clearance, Immunizations (Measles,
Pertussis, and Influenza) and required training. Based on records review, 2 out of 5 of the staff(S1& S2) have expired Mandated Reporter Training. Based on records review, staff (s3) is missing Measles and Stff (S4) is missing immunization records: (Measles, Pertussis, and Influenza) LPA reminded Director that the Mandated Reporter Training shall be renewed by all staff every two years. At least one staff member present during the inspection has current Pediatric CPR/First Aid certifications.

ncidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Continuation on next page:
SUPERVISOR'S NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: NISHIYAMATO ACADEMY PRESCHOOL, SAN JOSE
FACILITY NUMBER: 434413506
VISIT DATE: 06/12/2025
NARRATIVE
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Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP).

LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&R's) throughout California.

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.

As a result of this inspection, Four (4) Type B deficiencies are issued on the following pages:809-D. Appeal rights provided.

Exit interview conducted and report was reviewed with Director, Tomomi Kusuyama.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC809 (FAS) - (06/04)
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