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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434407129
Report Date: 02/01/2024
Date Signed: 03/26/2024 03:16:42 PM

Document Has Been Signed on 03/26/2024 03:16 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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:TASHIRO, NARUMIFACILITY NUMBER:
434407129
ADMINISTRATOR:TASHIRO, NARUMIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 586-8711
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
02/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Narumi TashiroTIME COMPLETED:
03:30 PM
NARRATIVE
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*This report is amended to include civil penalties for repeat violation of regulation 102425 (c)*
On 02/01/2024 at 12:40pm, Licensing Program Analyst (LPA), Farida Raja, conducted an unannounced case management inspection to follow-up on the deficiencies cited during the annual inspection conducted on 08/11/2023. LPA met with licensee, Narumi Tashiro and explained the purpose of today’s visit.

At 12:55pm, LPA toured the indoor and outdoor areas and observed licensee and daughter/assistant and seven children (2 infants and 5 preschool age) during today’s inspection. Licensee is operating within the ratio and capacity requirements of the license. Children were napping in cribs in the family room and off- limit bedroom during today's inspection. LPA informed licensee that according to facility sketch, master bedroom is off limits to children and cannot be used for daycare purposes. LPA advised licensee to submit an updated facility sketch. LPA provided Licensee with Safe Sleep Regulations PIN 20-24-CCP for reference.

LPA did not observe any baby bouncers in the on-limit areas. LPA reviewed seven children's files and did not observe the LIC 9224 Acknowledgement of Receipt of Licensing Report with parents' signatures for the Type A deficiencies cited on 08/11/2023 in 5 (C2, C3, C5-C7) out of 7 children's files. LPA did not observe an LIC 9227 Individual Infant Sleep Plan for one infant (C5) in care. LPA observed 15-minute nap check log for two infants in care.

Type B deficiencies were cited today on the attached LIC 809D pages. Appeal rights were printed and provided to Licensee. LPA reminded Licensee that failure to correct deficiencies by Plan of Correction Due Date may result in penalties of $100 per day per violation. Exit interview was conducted and report was reviewed with Licensee, Narumi Tashiro.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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 3
Document Has Been Signed on 02/02/2024 08:09 AM - It Cannot Be Edited


Created By: Farida Raja On 02/01/2024 at 02:06 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: TASHIRO, NARUMI
FACILITY NUMBER: 434407129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2024
Section Cited
CCR
102416.3(a)(6)

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Alterations to Existing Buildings or Grounds(a)Prior to making alterations... the licensee shall notify the Department of the proposed change...(6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to
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Licensee will submit an updated facility sketch indicating any changes or alterations to the facility and off limit and off limit areas. Licensee will submit plan of correction to LPA by 02/15/2024.
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children in care. This requirement is not met as evidenced by: LPA observed 2 infants and 1 preschooler napping in crib in the off limit master bedroom which poses a potential health, safety or personal rights risk to persons in care.
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Type B
02/15/2024
Section Cited
CCR102425(j)(5)

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Infant Safe Sleep (j) (5)If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.
This requirement is not met as evidenced by:
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LPA provided Licensee with Safe Sleep regulations PIN 20-24-CCP and informed her that when infants are napping in a separate room the door shall remain open at all times and licensee should visually be able to observe the children without moving the door.
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LPA observed that 2 infants and 1 preschooler was asleep in the master bedroom with the door closed while Licensee was in the living room which poses a potential health, safety or personal rights risk to persons in care.
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Licensee will submit a letter stating understanding of regulations to LPA by Plan of correction date of 02/15/2024.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Farida Raja
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2024 08:17 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/25/2024 02:04 PM


Created By: Farida Raja On 02/01/2024 at 02:26 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: TASHIRO, NARUMI
FACILITY NUMBER: 434407129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2024
Section Cited
HSC
1596.8595(c)(1)

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Posting licensing report by child care facility or home... reports to be provided to parents or guardian of each child receiving services (c)(1) A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents
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Licensee will provided parents with facility inspection report along with deficiencies cited on 08/11/2023 and have them sign the LIC 9224. Licensee will submit a copy of signed LIC 9224 for five children to LPA by 02/15/2024.
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any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b. This requirement was not met as evidenced by:
LPA observed no LIC 9224 with parents' signatures for the type A deficiencies cited on 08/11/2023 in 5 out of 7 children's files which poses a potential risk to the Health, Safety, or Personal Rights of children in care.

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Type B
02/15/2024
Section Cited
CCR102425(c)

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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.

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Licensee will have parents/authorized representatives complete required form and submit proof to LPA by plan of correction date of 02/15/2024.
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Based on observation., interview and record review, the licensee did not comply with the section cited above in one out of one infant which poses a potential health, safety or personal rights risk to persons in care.
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Civil Penalties in the amount of $250 are being assessed for a repeat violation on the LIC 421FC page dated 03/26/2024.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Farida Raja
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024


LIC809 (FAS) - (06/04)
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