<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313146
Report Date: 03/25/2025
Date Signed: 03/25/2025 12:29:52 PM

Document Has Been Signed on 03/25/2025 12:29 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:NAKAMURA, NORIKOFACILITY NUMBER:
304313146
ADMINISTRATOR/
DIRECTOR:		NAKAMURA, NORIKOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 331-3219
CITY:IRVINESTATE: CAZIP CODE:
92614
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
03/25/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Licensee, Noriko Nakamura TIME VISIT/
INSPECTION COMPLETED:
12:30 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
An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Dianna Valdez Santana who met with licensee, Noriko Nakamura census was taken. There were 9 children, 2 infants and 7 preschool children being cared for by licensee and her spouse. Licensee was operating within the licensed capacity as specified on license.

A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are 2 adults including the licensee and one minor living in the facility. Facility Day care hours are 8:00am-6:00pm, Monday through Friday.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas are made inaccessible by means of child safety gates and child safety knobs. The childcare area consists of the living room, dining room and one restroom. The outside backyard is currently an off-limit area, and the staff walk the children to the nearby playground. The children walk through the living/dining room to the bathroom. Licensee stated the children's primary area is the living room and dining room. There are working carbon monoxide, smoke detector alarms and fire extinguisher in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. There is a fireplace in the living room covered by a wooden cover to ensure it is inaccessible to children in care. The home has age-appropriate toys for the ages served. LPAs verified there is a working telephone service, which is the licensee’s cellphone. Licensee stated they use the playground nearby as their outdoor play area. There were no poisons or other items observed which could pose a danger to children. There are no bodies of water on the premises. Page 1 of 4.
NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Dianna ValdezSantana
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2025
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
Document Has Been Signed on 03/25/2025 12:29 PM - It Cannot Be Edited


Created By: Dianna ValdezSantana On 03/25/2025 at 11:29 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: NAKAMURA, NORIKO
FACILITY NUMBER: 304313146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(a)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 2 infants did not have a crib or play yard mattress, licensee had a bassinet for the 6 month old, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2025
Plan of Correction
1
2
3
4
Licensee will get rid of th bassinet and purchaae a play yard for the 6 month old infant by the POC due date. Licensee will email LPA at dianna.valdezsantana@dss.ca.gov send photos of the additional play yard (pack n play).
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
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out 2 staff did not have an approved EMSA Pediatric CPR/First Aid certification which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
1
2
3
4
Licensee and spouse will take an EMSA approved/American Heart Association/American Red Cross Pediatric First Aid/CPR in-person course by the POC due date. Licensee will email certificates.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Martha Malane
LICENSING EVALUATOR NAME:Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/25/2025 12:29 PM - It Cannot Be Edited


Created By: Dianna ValdezSantana On 03/25/2025 at 11:29 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: NAKAMURA, NORIKO
FACILITY NUMBER: 304313146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2025

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
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 2 staff did not have proof of required Immunizations which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
1
2
3
4
Licensee will email LPA a copy of required Immunizations including influenza and TB test by POC due date for licensee and spouse.
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
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 2 infants under 12 months of age did nave the Lic9227 in their files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
1
2
3
4
Licensee will email LPA completed LIC9227 forms for the the two infants by POC due date. Email: dianna.valdezsantana@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Martha Malane
LICENSING EVALUATOR NAME:Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: NAKAMURA, NORIKO
FACILITY NUMBER: 304313146
VISIT DATE: 03/25/2025
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
26
27
28
29
30
31
32
The licensee has a current roster of children in care. Children’s records for children present during LPAs’ inspection were reviewed. LPA reviewed 5 children’s files. LPAs reviewed LIC 9227 Individual Infant Sleeping Plan forms with licensee. The licensee’s unapproved Pediatric CPR/First Aid certification is current and expires 2/2026.

Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, 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. Proof of immunization against pertussis, measles for licensee and spouse/assistant were reviewed and not within compliance.

During today’s inspection, while LPAs were reviewing staff files, LPAs observed licensee, and her spouse did not have Mandated Reporter training certificates. The training is not offered in Japanese, so they are exempt from the training. Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years.

Incidental Medical Services (IMS) policy was discussed, and licensee stated she is not currently administering medication. 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 licensee understands she must be present in the facility, must ensure children in care are supervised at all times, and children are not to be left in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunization's, Pediatric CPR/First Aid, and mandated reporter training.



Page 2 of 4.
NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Dianna ValdezSantana
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: NAKAMURA, NORIKO
FACILITY NUMBER: 304313146
VISIT DATE: 03/25/2025
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
26
27
28
29
30
31
32
CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website.

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-and-resources/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.

English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspxNIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

· Always place infants on their backs for sleeping


· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold. Page 3 of 4
NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Dianna ValdezSantana
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: NAKAMURA, NORIKO
FACILITY NUMBER: 304313146
VISIT DATE: 03/25/2025
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
26
27
28
29
30
31
32
Safe sleep consultation provided during today's inspection. Safe sleep 15-minute log for infant present reviewed during today's consultation. LPA Valdez Santana asked Licensee if she had any questions or concerns about Infant Safe Sleep regulations 102425. A review of this regulation was provided to Licensee.

Based on LPAs’ observations, licensee did not have the LIC9227 for the two infants in care (under 12 months), 1 out of 2 infants did not have a play yard or crib, licensee had a bassinet. 2 out 2 staff did not have EMSA approved Pediatric CPR/First Aid certification, and 2 out 2 staff did not have copy of their Immunization record and TB test ready for review. See attached LIC 809D for Deficiencies.

In the areas that were evaluated, 4 Type B deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit. Deficiencies observed are Type B: 102425(c) Infant Safe Sleep, 102425(a) Infant Safe Sleep, 102416(c) Personnel Requirements, and 1597.622(a)(1) General Provisions and Definitions.


Exit interview conducted and report was reviewed with the licensee, Noriko Nakamuri. Appeal Rights and were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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.

Page 4 of 4. End of Report.

NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Dianna ValdezSantana
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6