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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013424125
Report Date: 03/26/2026
Date Signed: 03/26/2026 10:54:46 AM

Document Has Been Signed on 03/26/2026 10:54 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:ITO, CHIHIROFACILITY NUMBER:
013424125
ADMINISTRATOR/
DIRECTOR:		CHIHIRO ITOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 424-4221
CITY:BERKELEYSTATE: CAZIP CODE:
94703
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 0DATE:
03/26/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Chihiro ItoTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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On 03/26/2026 at 9:00 AM, Licensing Program Analysts (LPAs) Liam Bucsko and Kayla Merchant conducted an Announced Pre-licensing Inspection and met with Licensee Chihiro Ito who has applied for a Large Family Child Care Home with a capacity of fourteen (14). Living in the home are the Licensee, the Licensee's spouse, and the Licensee's minor child. Days and hours of operation will be Monday --- Friday from 8:30 AM --- 4:30 PM.

The Licensee has completed the 8 hour Preventative Health & Safety training, the Nutrition and Lead Poisoning training, has an 8 hour Pediatric CPR & First Aid Certificate that expires 01/2028, and has documentation for Measles, Pertussis, and an Influenza opt out statement for the current flu season. Licensee and adults living in the home have Criminal Record and Child Abuse Index Clearance and documentation for Tuberculosis (TB) clearance. The Licensee has completed and submitted an approved language-based waiver for Mandated Reporter training to the Department. Licensee has a working telephone in the home. Fire Safety Clearance was given to this facility on 03/16/2026 by the Berkeley Fire Department.

This is a two-story home which consists of 3 bedrooms, 2 bathrooms, office, below-stairs closet, dining room, living room, kitchen, laundry room, side yard, and gated water heater.

ON-LIMIT: Dining room, living room, first floor bathroom, backyard, and kitchen as a walk-through space to the bathroom and backyard.
OFF-LIMIT: Kitchen, laundry room, side yard, below-stairs closet, and the entire second floor consisting of 3 bedrooms, office, and 1 bathroom.
NAME OF LICENSING PROGRAM MANAGER: Sherelle Johnson
NAME OF LICENSING PROGRAM ANALYST: Liam Bucsko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2026
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 5
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: ITO, CHIHIRO
FACILITY NUMBER: 013424125
VISIT DATE: 03/26/2026
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INDOOR SPACE: LPAs toured the indoor space of the home. The home is sanitary and orderly, with heating and ventilation for safety and comfort. There are stairs in the home that are gated and made inaccessible to children in care. The fireplace located in the dining room is bolted closed by a metal gate. LPAs observed a fully charged 2A10BC fire extinguisher, a working smoke detector, and a working carbon monoxide detector. Medicines, cleaning products, and sharp objects are stored in places inaccessible to children. Door access to off-limit areas are made inaccessible to children. LPAs reminded the Licensee that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family child care homes. Licensee states that there are no firearms and ammunition stored in the home.

OUTDOOR SPACE: LPAs toured the outdoor areas. Children will be using the backyard and a local park for outdoor activity. The backyard contains 3 tires, 3 wooden benches, 1 plastic play structure, a covered storage area, and a gated hot water heater. The storage area, which is a section of the backyard space covered with tarp that is affixed to the fence, contains 3 locked and secured storage bins and an unused grill. The yard has fences on all sides. There is an off-limits side yard that is made inaccessible from the main backyard by a locked gate. In the main backyard space, there is a ledge of roughly two feet between an upper space that is covered with wood chips and a lower padded play space on concrete. LPAs advised the Licensee there needs to be 100% supervision when children are playing in the backyard. No bodies of water were observed. LPAs reminded the Licensee that when outside of the facility 100% supervision of children in care is required.

The Licensee provided proof of control of property. LPAs reminded the Licensee that when care for more than twelve and up to fourteen is provided, the licensee must notify parents and provide parents form LIC 9150 - Parent Notification of Additional Children in Care. The Licensee does carry liability Insurance and has provided proof to the Department.



The Licensee understands that children's personal rights should not be violated and no corporal punishment is permitted. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries and requirements for assistant/substitute were also discussed. Fire drills must be conducted once every six months and documented.
LPAs discussed and reminded the Licensee that the day care needs to be operated within the limitations and capacity of a Large Family Child Care Home with regards to ratios and that the Licensee must be present in the day care for 80% of operation hours.
NAME OF LICENSING PROGRAM MANAGER: Sherelle Johnson
NAME OF LICENSING PROGRAM ANALYST: Liam Bucsko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: ITO, CHIHIRO
FACILITY NUMBER: 013424125
VISIT DATE: 03/26/2026
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LPAs reviewed with the Licensee LIC 311D, Forms/Records to Keep in your Family Child Care Home, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the Licensee.

LPAs discussed the safe sleep regulations with the Licensee and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep, as an additional resource.
LPAs also informed the Licensee of the importance of checking for and removing recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at: https://www.cpsc.gov/, and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

The Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 licensed Family Child Care Home. 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.

On this date, 03/26/2026, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided:
NAME OF LICENSING PROGRAM MANAGER: Sherelle Johnson
NAME OF LICENSING PROGRAM ANALYST: Liam Bucsko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: ITO, CHIHIRO
FACILITY NUMBER: 013424125
VISIT DATE: 03/26/2026
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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, available at: http://www.ada.gov/childqanda.htm

The Licensee was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Website links for provider resources:
Licensing forms, Title 22 regulations, can be obtained through the internet at www.cdss.ca.gov
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters, and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/communitycare-licensing/subscribe and select the Child Care option to receive email communication.

The facility is recommended for licensure. License will be pending review by Licensing Program Manager.

Exit interview conducted and report was reviewed with Licensee Chihiro Ito.
A Notice of Site Visit was given to the Licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Sherelle Johnson
NAME OF LICENSING PROGRAM ANALYST: Liam Bucsko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
LIC809 (FAS) - (06/04)
Page: 5 of 5