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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413506
Report Date: 09/13/2022
Date Signed: 09/13/2022 02:25:03 PM


Document Has Been Signed on 09/13/2022 02:25 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:NISHIYAMATO ACADEMY PRESCHOOL, SAN JOSEFACILITY NUMBER:
434413506
ADMINISTRATOR:YURI MAEDAFACILITY TYPE:
850
ADDRESS:52 HAROLD AVENUETELEPHONE:
(408) 243-1174
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:66CENSUS: 31DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Yuri MaedaTIME COMPLETED:
02:50 PM
NARRATIVE
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On 09/13/2022 at 8:55 AM., Licensing Program Analyst, Kaur met with Director Yuri Maeda. Purpose of the inspection was explained and is for an Unannounced Annual/ Random inspection. Facility operates a preschool program. Present during inspection was the Director and 8 staff and 31 children. All staff have their criminal record clearances of file. Program utilizes three classrooms: Classroom #1,2,3,4. Hours of operation are Monday- Friday 8:30am- 3:30pm. Program operates year around. LPA inspected facility, indoors and outdoors, with director for health and safety hazards.


At 9:10AM., LPA observed the following: Preschool classrooms were clean, organized with age-appropriate toys, blocks and playthings. Floors and surfaces were free of obstructions or hazards. Furniture was in good repair. Toy were free of sharp objects, edges or splinters. Each classroom had several child size tables and chairs for snack and actives. Bathrooms were maintained in safe and sanitary condition. Facility had several cubbies and hangers for storage of children’s belongings. For nap time, each cot had been assigned and labelled for each child. Classrooms had acceptable ventilation and lighting. Accessible trash cans and outlets have been properly covered. Preschool bathroom, observed clean with adequate supplies for the children. Staff restrooms are located separate. All detergents, cleaning supplies and toxins are made inaccessible, stored in an off-limits area. Facility had a smoke/ carbon monoxide detector and several fully charged fire extinguisher (2A:10BC). First aid kit had been reviewed and is fully stocked.

(REFER TO 809-C FOR CONT.)
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Harsimran KaurTELEPHONE: (408) 529-3696
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
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


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: NISHIYAMATO ACADEMY PRESCHOOL, SAN JOSE
FACILITY NUMBER: 434413506
VISIT DATE: 09/13/2022
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(Page 2)
LPA inspected the outdoor play area. LPA observed outdoor play area is completely enclosed with tall fencing. Outdoor play area is kept clean, free of debris and hazardous items. Play structure and shaded rest area was properly anchored. Preschool activity schedule was provided during inspection. Per director, water service is provided inside and outside with large refillable containers.

At 10:00AM LPA review facility records including 12 children’s files and 6 personnel files. Children files reviewed are complete and included: Consent for Medical Treatment (LIC627), Identification of Emergency Information (LIC700), Immunization Records and Admissions Agreement. Staff files included: Health Screening (LIC503), Declaration to Report Suspected Child Abuse (LIC9108) and notice of Employee Rights (LIC9052)

Present staff members had their current CPR/ 1st aid certification which expires: 8/2023. Emergency drills are conducted at the facility, with the last drill done on 06/20/2022, properly logged. Per Director, parents provide all meals and snacks for day-care children. Required posting was observed in the facility entry way including: License, Parents Rights (PUB393), Emergency Disaster Plan (LIC610) and LIC613A.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manuel – Regulations Interpretations and Procedures for Child Care Centers Section 101173 and 101226. When an IMS is provided, an updated Plan of Operations that includes IMS must be submitted to the Department. Following information regarding ADA was provided: US Department of Justice (USDOJ) toll- free ADA information line at (800) 514- 0382 (TTY) and link to publications: Commonly asked questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

(REFER TO 809-C FOR CONT.)

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Harsimran KaurTELEPHONE: (408) 529-3696
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: NISHIYAMATO ACADEMY PRESCHOOL, SAN JOSE
FACILITY NUMBER: 434413506
VISIT DATE: 09/13/2022
NARRATIVE
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(Page 3)

Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in Child Care Center. A civil penalty of $100.00 minimum/ day up to $500.00 maximum per day/per person will be assessment if this regulation is violated.

LPA discussed safe sleep regulations with the director and discussed Child Care Licensing Safe Sleep webpage at http://www.cdss.ca.gov/inforesource/child-care-licensing/public-information-and-resouce/safe-sleep as an additional resource. LPA also informed director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at: http://www.cpsc.gov/ and recommend they register all infant devices with the CPSC to be notified of any recalls on their purchased requirement.

Based on today's inspection, no deficiencies were observed in the areas evaluated according the Title 22 Division 12 Ca. Code of Regulations. Exit interview was discussed with Director, Shanu Mathur and her signature of this form acknowledges receipt of these documents.



This report and rights to comment were discussed. This report must be available in the facility for public review. Notice was given and must remain posted for 30 days. Facility was advised any additional questions to call Office, M-F, 8am-5pm, 408/324/2148 or 1-844-538-8766. Website: www.ccld.ca.gov
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Harsimran KaurTELEPHONE: (408) 529-3696
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC809 (FAS) - (06/04)
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