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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073402110
Report Date: 05/19/2025
Date Signed: 05/19/2025 04:06:23 PM

Document Has Been Signed on 05/19/2025 04:06 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:TAKESHI, EZATFACILITY NUMBER:
073402110
ADMINISTRATOR/
DIRECTOR:		TAKESHI, EZATFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 952-4849
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 7DATE:
05/19/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Ezat TakeshiTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On 5/19/2025 at 1:00PM Licensing Program Analyst (LPA) Jaleesa Jackson arrived for an Unannounced Annual/Random Inspection and met with Licensee Ezat Takeshi. LPA informed Licensee of the nature of the visit and was granted entry into the home. Present for this inspection was the Licensee, her fingerprint cleared husband, her fingerprint cleared assistant, 3 preschool aged children, and 4 infants. The home was toured with the licensee to conduct a health and safety inspection. Hours of operation for day care are Monday through Friday, 7:30AM to 5:30PM.

ON LIMITS: Play Area (converted garage), Kitchen, Dining Area, Bedroom #1(2nd door right side of hallway), Bedroom #2 (3rd door right side of hallway), Bedroom #3 (1st door left side of hallway), Bathroom #1 (1st door right side of hallway) Bathroom #2 (end of hallway), and right side of backyard

OFF LIMITS: Laundry Room, Master Bedroom, Living Room, Family Room, Dining Room, and left side of Backyard

The home has heating and ventilation for safety and comfort. There were age appropriate toys that were observed to be safe and in good condition. During today's inspection all toxins, medicines, and hazardous items were inaccessible. There is a fully charged fire extinguisher, working smoke and carbon monoxide detector. Licensee stated that there are no firearms and no one who smokes at the home. Licensee states there are no pets in the home. The facility provides breakfast, lunch, and snacks to children. All children that bring their own snacks and lunches from home will be properly labeled and stored.

Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Jaleesa Jackson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2025
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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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: TAKESHI, EZAT
FACILITY NUMBER: 073402110
VISIT DATE: 05/19/2025
NARRATIVE
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LPA reviewed 6 children's files. One infant in care did not have a file to review at the time of the inspection. The infant is missing the LIC700, LIC627, LIC995, and LIC9227. 4 children do not have any immunizations records in their files. LPA reviewed Licensee's and both assistants files. Both assistants do not have proof of immunization for MMR, Tdap, or tuberculosis clearance in their files. Both Licensee and assistants CPR and First Aid are expired. Both Licensee and assistants mandated reporter training is expired. Disaster drills are conducted at least every six months. The last drill was conducted 01/03/2025. All required documents are posted by the front door

There were 7 deficiencies cited on today's inspection. See 809-D for deficiencies.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, 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.

LPA discussed the safe sleep regulations with 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. LPA also informed licensee of the importance of checking for 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.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Jaleesa Jackson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: TAKESHI, EZAT
FACILITY NUMBER: 073402110
VISIT DATE: 05/19/2025
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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

During the exit interview, the LICENSEE Ezat Takeshi, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Ezat Takeshi.

NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Jaleesa Jackson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 05/19/2025 04:06 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 05/19/2025 at 02:52 PM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: TAKESHI, EZAT
FACILITY NUMBER: 073402110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025

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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2
3
4
Based on record review, the licensee did not comply with the section cited above in both Licensee and 2 assistants do not have a current mandated reporter certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2025
Plan of Correction
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Licensee will email proof of completed mandated reporter training for child care providers for Licensee and 2 assistants to LPA by POC date 6/19/2025.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

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 in both Licensee and 2 assistants have expired pediatric CPR and First Aid which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2025
Plan of Correction
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2
3
4
Licensee will email proof of her payment and enrollment in an EMSA approved CPR and First Aid class (not online class) to LPA by POC date 6/19/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jason Jang
NAME OF LICENSING PROGRAM MANAGER:
Jaleesa Jackson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/19/2025 04:06 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 05/19/2025 at 02:52 PM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: TAKESHI, EZAT
FACILITY NUMBER: 073402110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home 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 in 2 out of 2 assistants do not have proof of immunization for MMR and Tdap on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2025
Plan of Correction
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Licensee will email proof of MMR and Tdap immunity for both assistants to LPA by POC date 6/19/2025.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

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 in 4 out of 7 children do not have immunizations in their files prior to starting day care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2025
Plan of Correction
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Licensee will email immunization records for all children without immunizations on file to LPA by POC date 6/19/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jason Jang
NAME OF LICENSING PROGRAM MANAGER:
Jaleesa Jackson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/19/2025 04:06 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 05/19/2025 at 02:52 PM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: TAKESHI, EZAT
FACILITY NUMBER: 073402110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 child does not have a file at the family child care home and 1 does not have a signed LIC627 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2025
Plan of Correction
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4
Licensee will email the completed LIC700, LIC627 for the infant missing the file as well as the second child missing the signed LIC627 to LPA by POC date 6/19/2025.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 4 infants do not have an infant sleep plan completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2025
Plan of Correction
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2
3
4
Licensee will email the completed LIC9227 for the infant to LPA by POC date 6/19/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jason Jang
NAME OF LICENSING PROGRAM MANAGER:
Jaleesa Jackson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025


LIC809 (FAS) - (06/04)
Page: 7 of 13
Document Has Been Signed on 05/19/2025 04:06 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 05/19/2025 at 02:58 PM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: TAKESHI, EZAT
FACILITY NUMBER: 073402110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102369(b)(9)
Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in Licensee's 2 out of 2 assistants do not have proof of TB clearance in their files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2025
Plan of Correction
1
2
3
4
Licensee will email proof of TB clearance for both assistants to LPA by POC date 6/19/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jason Jang
NAME OF LICENSING PROGRAM MANAGER:
Jaleesa Jackson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025


LIC809 (FAS) - (06/04)
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