434416724-6-16-2021-07-CC-JGSS-C42Q4J-20210616115027

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416724
Report Date: 06/16/2021
Date Signed: 06/16/2021 11:50:34 AM

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:	NISHIMUTA, YOKO		FACILITY NUMBER:	434416724
ADMINISTRATOR:	YOKO, NISHIMUTA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 460-4714
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	14	CENSUS: 0	DATE:	06/16/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Yoko Nishimuta		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) James Santos and Marilou Monico conducted an announced prelicensing inspection visit today. Applicant requested for a change of location application. LPAs met with Applicant, Yoko Nishimuta. Applicant is currently licensed at 289 Browning Avenue, Campbell, CA 95008 (Facility number: 434416378). 10:00 AM - Application/Record Review: LPAs observed the Applicant and her son are the only people in the home during today's inspection. The adults that reside in the home: Applicant and her mother. The Applicant also has a son, age 16 years old also residing in the home. The home is a one-story with 3 bedrooms and 2 bathrooms. Days and hours of operation will be Monday to Friday from 9:00 AM to 6:00 PM. The Applicant completed the California Child Care Preventative Health and Safety Course on 3/9/19. Lead Poisoning Prevention training was completed on 4/28/2021. The Applicant's CPR and First Aid certification is current (expires on 6/27/2022). Applicant's proof of completion of the Mandated Reporter Training for Child Care Providers was completed on 1/3/2021. The Applicant rents the home and provided a copy of the Real Estate Rental agreement. All individuals subject to a criminal record review have obtained a criminal record and child abuse index clearances prior to today's inspection. 10:10 AM - LPAs conducted a tour of the home with the Applicant (indoor/outdoor). The home is clean and organized with heating and ventilation for safety and comfort. There is a fireplace in the living room area that is barricaded. The off limit areas inside the home are the: 3 bedrooms, 1 bathroom, kitchen, laundry area and garage. There are no off limit areas outside the home except the storage shed. There are safe and age appropriate toys, play equipment, and materials for the children in the home. The Applicant has a designated area in the home where a child can be isolated if exhibiting signs of illness. The home has working smoke/carbon monoxide detectors (tested by LPAs during today's inspection).

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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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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: NISHIMUTA, YOKO	FACILITY NUMBER: 434416724
	VISIT DATE: 06/16/2021

NARRATIVE

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Physical Plant tour (cont.): The Applicant has one fire extinguisher (3A40BC) in the home that is fully charged. The Applicant states that she does not have any firearms and poisons in the home. All cleaning compounds and chemicals are securely stored (shelf in the garage) and inaccessible to the children. The Applicant understands that baby walkers, baby bouncers, jumpers, and saucer chairs are not allowed in the home. The Applicant states that no one in the home smokes and she understands that smoking is prohibited in the home. The Applicant has a first aid kit in the home, which also has a thermometer and sufficient emergency supplies.

10:15 AM - Kitchen tour: The kitchen area is gated. There are no sharp objects accessible to children. The Applicant understands that any food/drink which is brought by parent(s) of day care child(ren) must be properly labeled with the child(ren) name and properly stored or refrigerated.

10:20 AM - Bathroom tour: The toilets and faucets are clean, safe, and operable. The showers are free of any hazards. Sharp objects and cleaning products are stored inaccessible to children.

10:25 AM - Outdoor tour: The backyard is fenced. There were no bodies of water observed.

11:00 AM - Document/Regulation Review: Discussed and reviewed with the Applicant: 1) Child Care Facility Roster (LIC 9140) must be complete and current at all times, 2) Fire/disaster drills must be practiced at least once every 6 months and documented on the fire/disaster drill log provided to the Applicant, 3) Posting requirements - Parent's Rights (PUB 394), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), and Facility License, 4) Staffing & Ratio - capacity/ratio limitations handout, 5) Safe Sleep Regulations (PIN 20-24-CCP), 6) Lead Flyer Requirement (PIN 20-01-CCP), and 7) Forms and Records to keep in your Family Child Care Home (LIC 311D).

Forms of discipline used by Applicant: talk to the children and redirection. The Applicant understands that children's personal rights should not be violated; including no corporal punishment, supervision of children, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed with the Applicant during today's inspection.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: NISHIMUTA, YOKO	FACILITY NUMBER: 434416724
	VISIT DATE: 06/16/2021

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed with the Applicant during today's tele-inspection. 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. 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. The Applicant states that she does not plan on administering medication to the day care children at this time.

11:20 AM - Notification requirements/civil penalty: LPAs discussed the requirements of AB 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPAs discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected. LPAs reminded the Applicant of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

Fire clearance was granted on June 4, 2021.

LPAs conducted the exit interview and advised the Applicant that her large Family Child Care Home license will be approved upon completion of the following:

1. Applicant to notify analyst in writing when she plans to close her current license (Facility number: 434416378)
2. Manager's review and approval.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: James G Santos	TELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC809 (FAS) - (06/04)

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