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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415874
Report Date: 08/30/2023
Date Signed: 08/30/2023 11:09:11 AM

Document Has Been Signed on 08/30/2023 11:09 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
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: 6CENSUS: 1DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Nicole Danielle MattsonTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs) Mel Matos and Jessica Bongardt met with Nicole Danielle Mattson, Licensee, for an unannounced Required – 1 year annual inspection. LPAs were granted access to the home by the Licensee. LPAs also observed one infant day care child in the home during today's inspection. Licensee was operating within her capacity and ratio requirements. LPAs 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 and Licensee's spouse (Renz Joseph Lopez).

LPAs 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 does not have liability insurance and issues the Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282) to enrolled families. Licensee and her spouse has current CPR and First Aid certifications (expiration: January 2, 2024). Licensee and her spouse has the required vaccines (MMR, Tdap, & flu) and are current with her Mandated Reporter Training for Child Care Workers (expiration: 1/12/2024). LPAs reviewed three children's files and the files were complete with the required forms. LPAs reviewed two 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.

LPAs 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 or 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. LPAs 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: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MATTSON, NICOLE DANIELLE
FACILITY NUMBER: 434415874
VISIT DATE: 08/30/2023
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LPAs observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. 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 only provides (snacks) to the day care children. Licensee understands that any food brought from home (lunches) shall be labeled with each child's name and properly stored. 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 and her spouse 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 understands that she must comply with the capacity and ratio requirements of the small license whenever there is only one qualified adult 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.

Nicole Danielle Mattson, 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.

LPAs 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. LPAs also informed licensee [or facility representative] 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.

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.

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: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC809 (FAS) - (06/04)
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