434411686-11-17-2023-52-CC-EWOS-CXNR3R-20231117114023

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434411686
Report Date: 11/17/2023
Date Signed: 11/17/2023 11:40:29 AM

Document Has Been Signed on 11/17/2023 11:40 AM - 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 SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	MIYAGI, SHITEI		FACILITY NUMBER:	434411686
ADMINISTRATOR:	MIYAGI, SHITEI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 440-6296
CITY:	MOUNTAIN VIEW	STATE: CA	ZIP CODE:	94043
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 8	DATE:	11/17/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Shitei Miyagi		TIME COMPLETED:	12:00 PM

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On November 17, 2023, at 9:15 AM, Licensing Program Analyst (LPA) Elimika Woods met with licensee Shitei Miyagi for an Unannounced 3 Required Year Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. Present during the inspection was the licensee's fingerprint cleared son, Shimon Miyagi, two fingerprint cleared assistants Motoe Kubota and Takako Yanase, two infants, six preschool age children and Kamilah Cole who is a Bay Area Behavior Technician. Licensee stated that the facility operates from Monday to Friday 8:30 AM to 5:30 PM.

LPA toured the facility inside and outside to conduct a Health and Safety inspection. This single story home was clean and orderly, with heating and ventilation for the safety and comfort of children in care. The Isolation area of the home will be the bedroom across the hallway bathroom, away from other children in care.

The off-limits are will be made inaccessible by closed and/or locked doors and visual supervision. There's a gate at both kitchen entrances to keep children out of the kitchen and a gate in the hallway to prevent children from going into the off limits areas. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection. There are no pools, hot tubs or any other bodies of water present in the on-limit areas during today's inspection

The home has a working smoke detector, working carbon monoxide detector, telephone, and fully charged 2A10BC fire extinguisher which meets standards established by the State Fire Marshal and centralized heating. Per licensee, there are no firearms in the home. LPA asked the licensee does he transport children and the licensee stated that he does not transport children.

The OFF-LIMIT AREAS are two back bedrooms, back bathroom, kitchen, back and sideyard beyond white gates and garage

The ON-LIMIT AREAS are the two front bedrooms, front bathroom, living room, dining area, & backyard.

See 809-C for continuance

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Elimika Woods
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: MIYAGI, SHITEI	FACILITY NUMBER: 434411686
	VISIT DATE: 11/17/2023

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The OUTDOOR PLAY area is the fully fenced backyard and LPA observed that it is free from defects or dangerous conditions. During today's inspection, there are no play structures which are required to be anchored. There are ample age appropriate toys that appear to be safe and in good condition. There's a shed with a lock to prevent children access to equipment in the backyard. The side and backyard beyond the white gate is off limits to children in care.

At 10:15 AM LPA requested and reviewed the files of three (3) children in care and one staff file. All children files contain Immunization, Parent's Rights, and Medical Consent forms and the staff file has the required Employee Rights and Health Screening records. The facility roster was reviewed, and copies were obtain. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 07/31/23. The licensee's Health and Safety training is completed, and CPR and First Aid certificate is current and expires 12/2024. The licensee and assistant has completed mandated reporter training on 11/06/2022. The licensee is in compliance with the immunization laws which pertains to all childcare providers. All required forms are posted and visible for public review. The licensee is in ratio today

Effective August 1, 2003 California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail. LPA informed the licensee that all forms can be downloaded at www.ccld.ca.gov and encouraged the licensee to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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/.

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.

See 809-C

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Elimika Woods
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

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 SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: MIYAGI, SHITEI	FACILITY NUMBER: 434411686
	VISIT DATE: 11/17/2023

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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.

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

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

There are no deficiencies cited today. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Shitei Miyagi.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Elimika Woods
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC809 (FAS) - (06/04)

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