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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434411686
Report Date: 07/19/2024
Date Signed: 07/19/2024 11:04:55 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/31/2024 and conducted by Evaluator Christina Uribe
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20240531153240
FACILITY NAME:MIYAGI, SHITEIFACILITY NUMBER:
434411686
ADMINISTRATOR:MIYAGI, SHITEIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 440-6296
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94043
CAPACITY:14CENSUS: 8DATE:
07/19/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shitei MiyagiTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Licensee uses inappropriate forms of discipline.
INVESTIGATION FINDINGS:
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On 07/19/2024, at 10:00am, Licensing Program Analyst (LPA) Christina Uribe conducted an unannounced visit for the purpose of a complaint investigation for the above allegation of personal rights violation and met with licensee, Shitei Miyagi. Also present at the time of today’s inspection are 2 fingerprint cleared assistants and 8 day care children.

Based on evidence received it was found that the licensee has lightly hit the back of a child's hand as a form of discipline. The preponderance of evidence standard has been met, therefore the above allegation that the license uses inappropriate forms of discipline is SUBSTANTIATED. California Code of Regulations, Title 22, Division 12, Chapter 1, Article 6, Section 102423(a)(4) – Personal Rights is being cited on the attached LIC 9099D.

Report was reviewed and a notice of site visit was given and must remain posted for 30 days. Appeal rights were given. Exit interview was conducted with the licensee, Shitei Miyagi.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 52-CC-20240531153240
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: MIYAGI, SHITEI
FACILITY NUMBER: 434411686
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2024
Section Cited
CCR
102423
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Personal Rights - 102423 (a) Each child receiving services from a family child care home shall have certain rights…(4) To be free from corporal punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature.
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The licensee and the assistant will create a written statement summarizing Personal Rights to children in care. This written statement will also include a plan for how the licensee and assistant will address behavioral concerns to children in a productive manner that will not violate Personal Rights.
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This requirement was not met as evidenced by:

The licensee and one assistant were observed by witnesses to hit children on the back of the hand as a form of discipline.
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This written statement will be signed and dated by the licensee and the assistant and will be emailed to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 08/02/2024.
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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.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/31/2024 and conducted by Evaluator Christina Uribe
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20240531153240

FACILITY NAME:MIYAGI, SHITEIFACILITY NUMBER:
434411686
ADMINISTRATOR:MIYAGI, SHITEIFACILITY TYPE:
810
ADDRESS:2332 JEWELL PLACETELEPHONE:
(408) 440-6296
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94043
CAPACITY:14CENSUS: 8DATE:
07/19/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shitei MiyagiTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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5
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8
9
Licensee hit daycare child.
INVESTIGATION FINDINGS:
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13
On 07/19/2024, at 10:00am, Licensing Program Analyst (LPA) Christina Uribe conducted an unannounced visit for the purpose of a complaint investigation for the above allegation of personal rights violation and met with licensee, Shitei Miyagi. Also present at the time of today’s inspection are 1 fingerprint cleared assistant and 8 day care children.

Based on evidence received, the preponderance of evidence standard has been met, therefore the above allegation that the license hit daycare child is SUBSTANTIATED. California Code of Regulations, Title 22, Division 12, Chapter 1, Article 6, Section 102423(a)(4) – Personal Rights is being cited on the attached LIC 9099D.

Report was reviewed and a notice of site visit was given and must remain posted for 30 days. Appeal rights were given. Exit interview was conducted with the licensee, Shitei Miyagi.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4