434415874-6-2-2026-07-CC-FRAA-DUNP3X-20260602105816

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415874
Report Date: 06/02/2026
Date Signed: 06/02/2026 10:58:29 AM

Document Has Been Signed on 06/02/2026 10:58 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
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: 5	CENSUS: 2	DATE:	06/02/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Nicole Danielle Mattson		TIME VISIT/ INSPECTION COMPLETED:	11:10 AM

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	On 06/02/2026, Licensing Program Analyst (LPA), Farida Raja, conducted an unannounced annual/random inspection. LPA was granted access to the home by Licensee, Nicole Mattson and explained the nature of today’s inspection. Present in the home were licensee, spouse and two children including licensee's infant son and one preschool child. Licensee is operating within the ratio and capacity requirements of the license. Days and hours of operation are Monday to Friday, 8:00 AM to 4:45 PM. LPA observed all required posted materials in the living room/play area. Two adults including licensee and one minor child reside in the home. Licensee provided LPA with a copy of the updated Application for a Family Child Care Home License (LIC 279), Current Children in the Home (LIC 279B) and Updated Facility Sketch indicating Bedroom 1 as off limits during today's inspection. LPA toured the indoor and outdoor areas of the home. Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. Furniture was observed in good condition. LPA observed barricaded wall heaters in the living room/ play area and in the hallway to the bathroom. Licensee uses wall mounted air conditioner and free standing fans to maintain a comfortable temperature. The home is single story. There are no stairs or fireplaces inside the home. Off limit areas inside the home include master bedroom, master bathroom, bedroom 1, bedroom 2, gated kitchen, office and attached garage. LPA observed door knob locks on the door leading to the garage. LPA reminded Licensee to notify the Department when any change from an area of the family child care home previously identified as off limits is changed to an area where care and supervision will be provided to children in care. There is a 3A40BC fire extinguisher which was last serviced on 12/30/2025 near the dining area and working smoke and carbon monoxide detector in the play area. Continued on Page 2

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

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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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)

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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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MATTSON, NICOLE DANIELLE	FACILITY NUMBER: 434415874
	VISIT DATE: 06/02/2026

NARRATIVE

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LPA reminded licensee that fire extinguishers need to be serviced once every 12 months and service tag or proof of purchase needs to be maintained for review. Licensee states that she does not have any firearms or pets in the home. All detergents, cleaning compounds, poisons, medications, sharp objects and other similar items were observed to be stored inaccessible to children. Licensee understands that smoking is prohibited in the home.

LPA inspected the on limit outdoor area during today's inspection. The outdoor play area used by children was observed to be fenced. Sandbox was observed to be covered. Shade is provided by canopies. There were no toys and Licensee stated that children only use the outdoor area sometimes to eat lunch. LPA observed picnic tables for the children. LPA advised Licensee to check the outdoor area for any hazards and remove any children's toys and equipment that is in disrepair prior to allowing access to children. There are no bodies of water observed. Off limit areas outdoors include the left side yard and backyard with storage shed. LPA observed a patio swing in the front yard that is in disrepair. Licensee stated that children do not play in the front yard and it is only used to enter and leave the facility.

Bathroom used by children was in operating condition. Toilets and faucet are clean and operable. The shower area is free of hazards.

Drinking water is readily available for children in the home via individual water bottles and refilled using water dispenser. Licensee states that parents currently provide all meals and snacks. Licensee understands that any food brought from home shall be labeled with each child's name and properly stored or refrigerated. Licensee states that a child will be isolated in the play area away from other children if necessary due to illness or communicable disease.

LPA reviewed a current child care facility roster and fire/disaster drill log during today's inspection. Fire/disaster drill was last conducted on 04/24/2026. LPA obtained copy of children's roster.

Two children's files were reviewed and found to be current and up to date. Licensee does not have liability insurance for the day care and issues the Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282) to all families. LPA reviewed one infant's file and the file was complete with the required forms, including the 15 minute sleep log.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MATTSON, NICOLE DANIELLE	FACILITY NUMBER: 434415874
	VISIT DATE: 06/02/2026

NARRATIVE

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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-and-resources/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.

LPA reviewed Licensee's[] file for the required forms. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances. Licensee has current Pediatric CPR/First Aid certification which expires on 01/18/2027 and current mandated reporter training which expires on 06/02/2027. Licensee has the required immunization's in file for measles, pertussis and influenza.

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.

Supervision of children was discussed with Licensee, and she understands that she or a qualified adult must be present in the home during day care hours and ensure that the children are supervised at all times. LPA discussed "zero tolerance" related regulations which includes the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. A $500 immediate civil penalty is assessed for serious violations such as absence of supervision, accessible bodies of water, accessible firearms, refused entry of licensing staff, presence of an excluded person, and violations that result in illness or injury. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

LPA discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to resources such as forms, regulations Provider information Notices (PINs) and Quarterly Updates. LPA discussed Reporting Requirements as outline in the regulations (Section 102416.2).

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MATTSON, NICOLE DANIELLE	FACILITY NUMBER: 434415874
	VISIT DATE: 06/02/2026

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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. Licensee states that no children require medications or IMS at this time. 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/.

Licensee states that she does not transport any day care children. LPA reminded Licensee that if she decides to transport children, 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.

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.

No deficiencies were cited as a result of today's inspection. Appeal rights were provided.

Exit interview conducted and report was reviewed with Licensee, Nicole Mattson. During the exit interview, Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

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: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC809 (FAS) - (06/04)

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