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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629307
Report Date: 03/05/2025
Date Signed: 03/05/2025 01:21:44 PM

Document Has Been Signed on 03/05/2025 01:21 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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:KUSANO, AYAKO FAMILY CHILD CAREFACILITY NUMBER:
376629307
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 9DATE:
03/05/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Ayako KusanoTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
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On 03/05/2025 at 10:10AM, Licensing Program Analyst (LPA) Saul Zazueta conducted an unannounced Annual inspection with Licensee, Ayako Kusano. LPA disclosed the purpose of the inspection and was led on a tour of the facility, both indoors and outdoors. This facility is a one-story, three (3) bedroom, two (2) bathroom house. The following areas are used for childcare: living room, kitchen, day care room, and bathroom #1. Off limits areas include bedroom #1, bedroom #2, bedroom #3, bathroom #2, and garage. Licensee stated that they use the garage for activities. LPA observed foam mats and a piano in the garage, which the licensee stated is used for dance time. All other off-limits areas are inaccessible to children by use of safety gates and locking doors. Days and hours of operation are Monday through Friday, 8:30AM to 2:30PM. There were nine (9) children, from the ages of 2 to 4, and one assistant present during the inspection.

The fire extinguisher met requirements and were observed to be operational. LPA observed the smoke detector to be in a drawer in the living room with no batteries. Licensee stated that this is the only smoke detector in the home, and she removes it because it is sensitive to cooking smoke. LPA did not observe a carbon monoxide detector and licensee stated that they do not know what that is. LPA informed licensee that poisons, detergents, cleaning compounds, medications and other hazardous items shall be placed in a storage area and locked. LPA observed “Pink Stuff” cleaning compound and pet care products in an unsecured cabinet located underneath the sink in bathroom #1. Kitchen knives and all other hazardous items were made inaccessible to children by use of cabinet locks. Backyard is used for outdoor activities. LPA informed licensee to ensure that children are supervised at all times during outdoor activities. There is no fireplace in the home. Licensee stated that there are no pool or bodies of water on the premises, which was confirmed by LPA during inspection. Licensee has children's toys, play equipment and books available. Licensee has a working cell phone. Licensee stated that there are no firearms, other weapons, or ammunition in the home.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Saul Zazueta
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KUSANO, AYAKO FAMILY CHILD CARE
FACILITY NUMBER: 376629307
VISIT DATE: 03/05/2025
NARRATIVE
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A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions.

LPA reviewed children’s files and found files to be incomplete. LPA observed two children present without required documentation. Licensee stated that they just started, and their parents have not submitted any paperwork yet.

Licensee and assistant are prominently Japanese speaking and are exempt from the Mandated Reporter AB1207. The Licensee completed 8 hours of preventative health which included nutrition and lead training on 11/20/2021. Pediatric CPR and First Aid certification expired on 12/04/2023. Licensee has required immunizations, per file review. Parents Rights Poster was not observed to be posted at the time of inspection. Facility roster is not maintained by licensee. The licensee has not conducted fire and disaster drills.

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 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. 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.

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/.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Saul Zazueta
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
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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 DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KUSANO, AYAKO FAMILY CHILD CARE
FACILITY NUMBER: 376629307
VISIT DATE: 03/05/2025
NARRATIVE
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Licensee was informed the following items are prohibited during day care operating hours (walkers, exersaucers, jumpers and bouncy seats). Corporal punishment and smoking are not allowed in the day care. LPA reviewed with licensee the LIC 311D, Forms/Records to Keep in Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

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 platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

On this date, 03/05/2025, 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 addresses. 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. LPA discussed California Megan's Law with licensee and provided: www.meganslaw.ca.gov.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) 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.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Saul Zazueta
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC809 (FAS) - (06/04)
Page: 3 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KUSANO, AYAKO FAMILY CHILD CARE
FACILITY NUMBER: 376629307
VISIT DATE: 03/05/2025
NARRATIVE
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Per California Code of Regulations, (Title 22, division 12 & Chapter 3) one (1) Type A citations, eight (8) Type B are being cited on the attached LIC 809-D.

LPA, Saul Zazueta, informed Licensee, Ayako Kusano, that this report, dated 03/05.2025, documents one (1) Type A citation(s), which shall be posted for 30 consecutive days as there is immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA, Saul Zazueta, informed the Licensee, Ayako Kusano, to provide a copy of this licensing report dated 03/05/2025 that documents Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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

During the exit interview, the Licensee, Ayako Kusano, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

An exit interview was conducted, and this report was reviewed with Licensee, Ayako Kusano.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Saul Zazueta
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 03/05/2025 01:21 PM - It Cannot Be Edited


Created By: Saul Zazueta On 03/05/2025 at 12:23 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: KUSANO, AYAKO FAMILY CHILD CARE
FACILITY NUMBER: 376629307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(c)
Staffing Ratio and Capacity
(c) The total licensed capacity for a Small Family Child Care Home shall not exceed eight children.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in that there were 9 children from ages 2-4yrs old present at the time of inspection, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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2
3
4
Licensee stated that they will immediately call the parents of three (3) children to pick up their child as soon as possible to bring the number down from 9 children, to 6 children between the ages of 2-4yrs old.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jason Garay
LICENSING EVALUATOR NAME:Saul Zazueta
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 03/05/2025 01:21 PM - It Cannot Be Edited


Created By: Saul Zazueta On 03/05/2025 at 12:23 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: KUSANO, AYAKO FAMILY CHILD CARE
FACILITY NUMBER: 376629307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that there was no carbon monoide detector present at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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Licensee stated that they will purchase and install a carbon monoxide detector in the facility and send proof to the San Diego Regional Office (SDRO) by 04/04/2025.
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are 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 that cleaning compounds and pet care products were found to be in an unsecured cabinet beneath the sink in the bathroom that the children use, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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Licensee stated that they will remove hazardous items from bathroom cabinets, making the items innaccessible to children in care. Licensee will submit proof to the SDRO by 04/04/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jason Garay
LICENSING EVALUATOR NAME:Saul Zazueta
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 03/05/2025 01:21 PM - It Cannot Be Edited


Created By: Saul Zazueta On 03/05/2025 at 12:23 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: KUSANO, AYAKO FAMILY CHILD CARE
FACILITY NUMBER: 376629307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not comply with the section cited above in that fire drills are not documented on a log, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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Licensee stated that they will maintain a fire drill log and document a fire drill by 03/17/2025, and provide proof to the SDRO.

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:Jason Garay
LICENSING EVALUATOR NAME:Saul Zazueta
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 03/05/2025 01:21 PM - It Cannot Be Edited


Created By: Saul Zazueta On 03/05/2025 at 12:23 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: KUSANO, AYAKO FAMILY CHILD CARE
FACILITY NUMBER: 376629307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 interview and record review, the licensee did not comply with the section cited above in that they do not have a current CPR card on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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2
3
4
Licensee stated that they will register for a Pediatric CPR and First Aid course by 03/17/2025 and submit proof to the SDRO.
Type B
Section Cited
CCR
102416.3(a)(1)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (1) Conversion of a garage (either attached or detached) into a "child care" room.

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 that they converted their garage into a child care room without notification or approval from the department, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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2
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Licensee stated that they will cease use of the garage and submit an updated facility sketch, (LIC999A) and application (LIC279) that includes the garage to the SDRO for review by 03/17/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jason Garay
LICENSING EVALUATOR NAME:Saul Zazueta
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 03/05/2025 01:21 PM - It Cannot Be Edited


Created By: Saul Zazueta On 03/05/2025 at 12:23 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: KUSANO, AYAKO FAMILY CHILD CARE
FACILITY NUMBER: 376629307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(b)
Admission Procedures and Authorized Representatives Rights
(b) The licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family child care home at all times children are in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that there was no PUB 394 posted at the time of inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
1
2
3
4
Licensee stated that they will keep a copy of the Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family child care home and send proof to the SDRO by 03/17/2025.
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that 9 out of 9 child's files reviewed were missing documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
1
2
3
4
Licensee stated that they will ensure that all children in care have complete files including the LIC700, LIC627 LIC995, LIC282, LIC9150, and CDPH286, (as stated on the provided LIC311D). Licensee also stated that they will not admit any children prior to obtaining all completed forms. Licensee stated that they will submit proof of completed files to the SDRO by 03/17/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jason Garay
LICENSING EVALUATOR NAME:Saul Zazueta
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 03/05/2025 01:21 PM - It Cannot Be Edited


Created By: Saul Zazueta On 03/05/2025 at 12:23 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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: KUSANO, AYAKO FAMILY CHILD CARE
FACILITY NUMBER: 376629307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

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 that they do not maintain a child roster at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
1
2
3
4
Licensee stated that they will complete and maintain a child roster at the facility and submit proof to the SDRo by 04/04/2025.
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.
SUPERVISOR'S NAME:Jason Garay
LICENSING EVALUATOR NAME:Saul Zazueta
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
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