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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415874
Report Date: 03/10/2022
Date Signed: 03/10/2022 12:29:12 PM

Document Has Been Signed on 03/10/2022 12:29 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MATTSON, NICOLE DANIELLEFACILITY NUMBER:
434415874
ADMINISTRATOR:MATTSON, NICOLE DANIELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 507-0204
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 3DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nicole Danielle MattsonTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Mel Matos met with Nicole Danielle Mattson, Licensee, for an unannounced Required – 1 year annual inspection. LPA was granted access to the home by the Licensee. LPA also observed three day care children (1 infant & 2 preschool) and one adult assistant (Sherwin Ganaden) in the home during today's inspection. Licensee was operating within her capacity and ratio requirements. LPA observed the required postings, including the facility license, near the front entrance to the home. Days and hours of operation are Monday - Friday from 7:00 AM to 5:30 PM. The adults residing in the home are: Licensee, Licensee's spouse (Renz Joseph Lopez), and one adult renter (Kendelle Cummings).

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on December 9, 2021. Licensee states that she has liability insurance through DCI Insurance and LPA observed a current policy verifying valid coverage. Licensee has current CPR and First Aid certifications (expiration: January 2, 2024). Licensee has the required vaccines (MMR, Tdap, & flu) and is current with her Mandated Reporter Training for Child Care Workers (expiration: 1/2/2024). Licensee's adult assistant also has the required vaccines (MMR, Tdap, & flu) and is current with his Mandated Reporter Training for Child Care Workers (expiration: 10/20/2021). LPA reviewed three children's files and the files were complete with the required forms. LPA reviewed three staff files and the files were complete with the required forms. Licensee states that a child will be isolated in one bedroom if necessary due to illness or communicable disease.

LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. The home is clean, orderly, (including heating/air conditioning/ventilation), and safe for the day care children. There are safe and age appropriate toys, play equipment, and materials for the children in the home. There are no stairs in the home. There are fireplace units in the home. The Licensee has two barricaded wall heater units in the home. Off limit areas inside the home: master bedroom, master bathroom, bedroom 2, two barricaded wall heaters, and attached garage. LPA did not observe any wall heaters inside the home. Off limit areas outside the home: left side yard and back section of the backyard.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MATTSON, NICOLE DANIELLE
FACILITY NUMBER: 434415874
VISIT DATE: 03/10/2022
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LPA observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. The Licensee states that she does not have any weapons or pets in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Licensee states that there are no poisons in the home. Licensee states that she does not administer any medication to the day care children at this time. Licensee has a first aid kit in the home which includes a touch less thermometer. Licensee states that she, her spouse, and adult renter don't smoke and she understands that smoking is prohibited in the home.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity/ratio options and she understands that she cannot have more than 14 children present in the home without two qualified adults present. Licensee states that does not transport any day care children. Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with the 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 as an additional resource. LPA also informed the 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.

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

Exit interview conducted and report was reviewed with the Licensee, Nicole Danielle Mattson. No deficiencies issued during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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