434415874-6-4-2025-07-CC-AMEA-DHBR4Y-20250604124218

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415874
Report Date: 06/04/2025
Date Signed: 06/04/2025 12:43:02 PM

Document Has Been Signed on 06/04/2025 12:43 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	MATTSON, NICOLE DANIELLE		FACILITY NUMBER:	434415874
ADMINISTRATOR/ DIRECTOR:	MATTSON, NICOLE DANIELLE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 507-0204
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94089
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 7	CENSUS: 3	DATE:	06/04/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Nicole Danielle Mattson		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs), Albert Mendoza, Jaime Gonzales & Jennifer “Jen” Beehler, met with Licensees, Nicole Danielle Mattson for an unannounced Annual/Random Inspection. LPAs were granted access to the home by the Licensees and toured both indoors and outdoors during the inspection. Upon arrival, there were 4 children (2 preschool-age & 2 infants) and licensee present, which is compliant with the home license capacity and ratio requirements. LPAs observed all required postings near the entrance to the home. Hours of operation for the facility are Monday – Friday,8:00AM- 05:00PM. There are no active waivers. Licensees state that adults, over the age of 18, residing in the home are: are her and her husband. The licensee has one child in the home that is 3 months old. 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. All adults have criminal record clearance and are associated on the Guardian Roster for the facility. LPAs reviewed facility roster (LIC9040) and fire/disaster drill log during todays inspection. The last fire/disaster drill was conducted on 12/16/2024, which is compliant with the six month requirement for homes. LPAs observed a fully charged 3A40BC fire extinguisher last serviced on 01/3/2025 which is compliant with State Fire Marshall Regulations. Continued on Page 2

NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Albert Mendoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

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 6

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MATTSON, NICOLE DANIELLE	FACILITY NUMBER: 434415874
	VISIT DATE: 06/04/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Indoor areas of the home were inspected by the LPAs today and observed to be clean, orderly, and safe for the day care children. Off-limits areas of the home (indoors): 3 bedrooms, kitchen, master bathroom, and garage. There is no fire place in the facility. LPAs observed sufficient age-appropriate materials, toys, and play equipment in the home. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. Drinking water is readily available for children in the facility via water dispensers and water bottles from home labeled with the children’s names. The bathroom in the home is clean, sanitary, and operable.

The backyard area of the home was inspected. LPAs observed sufficient play equipment and supplies for the children that are in good condition and age-appropriate. Off-limit areas outside of home include: the Left side of the backyard that is fenced as well as one storage unit. No outdoor bodies of water were observed during todays inspection.

LPAs reviewed four children's files and observed all forms are completed and children have current immunization records. Licensee states day care is not insured and has LIC 282. LPAs did not observed a safe sleep log for both infants in care. Infant Safe Sleep regulations (PIN 20-24-CCP) were discussed with the Licensees, including the Individual Infant Sleeping Plan (LIC9227). LPAs reminded Licensees that infants up to 12 months of age should be placed on their back to sleep, that cribs should be free of all loose articles and hanging objects, and that infants should not be swaddled. LPAs observed a loose blanket and pillow in the infant's crib upon arrival.

Continued on Page 3

NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Albert Mendoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

LIC809 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MATTSON, NICOLE DANIELLE	FACILITY NUMBER: 434415874
	VISIT DATE: 06/04/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPAs reminded Licensees that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping. LPAs reminded licensees that all equipment used in the day care must follow manufacturer's instructions for use.

During today's inspection the following documents were collected:

Updated LIC999 Sketch of the Interior of the Facility
Updated LIC9040 Roster
Updated LIC279B showing newborn son

Licensee stated adults in home have changed along with daycare hours. Licensee will submit to LPA an updated LIC279 reflecting all facility changes.

As a result of todays inspection, 2 Type B deficiencies have been cited. More information provided on the attached LIC809-D pages. Exit interview conducted with licensee Nicole Danielle Mattson, report was reviewed and provided along with appeal rights.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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

NAME OF LICENSING PROGRAM MANAGER: Susy Cervantes
NAME OF LICENSING PROGRAM ANALYST: Albert Mendoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 06/04/2025 12:43 PM - It Cannot Be Edited

Created By: Albert Mendoza On 06/04/2025 at 12:22 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MATTSON, NICOLE DANIELLE	FACILITY NUMBER: 434415874
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(b)

Infant Safe Sleep

(b) Cribs or play yards shall be free from all loose articles and objects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one out of one pack in plays which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/04/2025
	Plan of Correction
1 2 3 4	Liceense Cleared out the pack and play during inspection. Licensee stated with future use she will comply with Infant sleep regulations.

Type B

Section Cited

CCR

102425(j)(2)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two out of two safe sleep logs which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/13/2025
	Plan of Correction
1 2 3 4	Licensee wil Submit to CDSS a week worth (6/4/2025-6/11/2025) of Infant safe sleep logs for both infants. These logs will contain childs name, time of check, who checked on child, child's condtion. Licensee will maintain sleep logs for all infants under the age of two and will keep proof in child's records.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Susy Cervantes
NAME OF LICENSING PROGRAM MANAGER:

	Albert Mendoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

LIC809 (FAS) - (06/04)

Page: 5 of 6