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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416474
Report Date: 01/15/2026
Date Signed: 01/15/2026 03:55:04 PM

Document Has Been Signed on 01/15/2026 03:55 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:MOHAMMAD, SURIYAFACILITY NUMBER:
434416474
ADMINISTRATOR/
DIRECTOR:		SURIYA MOHAMMADFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 457-4279
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
01/15/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Suriya MohammadTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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On 01/15/2026 Licensing Program Analyst (LPA), Farida Raja, conducted an unannounced annual/random inspection. LPA was granted access to the home by Licensee, Suriya Mohammad, and explained the nature of today’s inspection. The entrance to the facility is through the right side gate. Present in the home were licensee, one assistant, S2 and twelve children including three infants and nine preschool age. Licensee is operating within the ratio and capacity requirements of the license. Days and hours of operation are Monday to Sunday, 5:30 AM to 8:00 PM. LPA observed all required posted materials in the daycare room. Two adults and no minor children reside in the home. Licensee to submit an updated Application for a Family Child Care Home License (LIC 279) to LPA with updated hours by 01/30/2026.

LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. Children were observed to be napping during today's inspection. Infants were observed to be napping in play yards with loose items like blankets and waterproof mats placed on the play yard mattress. LPA also observed a milk bottle and cap inside infant's play yards. Licensee stated that she placed the extra blankets and mats for cushioning to prevent children from injuries. LPA reminded Licensee about safe sleep regulations and provided Licensee with a copy of PIN 20-24-CCP. The home has central heating/cooling and ventilation for comfort of children. There are no stairs or fire places in the areas on limit to children in care. Off limit areas inside the home: living room, laundry room, kitchen, one bathroom and attached garage. On limit areas include: family room, master bedroom and one bathroom. Off limit areas outside the home: gated left side section. The outdoor space and play equipment were observed to be age appropriate. Shade is provided by several canopies. There are no bodies of water observed. Outdoor toys in a one fenced section were observed to be in disrepair and Licensee stated that children are not allowed in that area at present.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2026
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: MOHAMMAD, SURIYA
FACILITY NUMBER: 434416474
VISIT DATE: 01/15/2026
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Licensee states that she is working on fixing the broken part and will permit access to children once fixed. LPA observed that the bathroom used by children was in operating condition. Toilets and faucet are clean and operable.

LPA observed a 2A10BC fire extinguisher in the master bedroom which was last serviced on 12/09/2025 and working smoke/carbon monoxide detector. Licensee states that she does not have any weapons or pets in the home. LPA reminded Licensee that all detergents, cleaning compounds, poisons, medications, sharps including knives and other similar items need to be stored inaccessible to children or in child locked cabinets. Licensee understands that smoking is prohibited in the home.

Drinking water is readily available for children in the home via individual water bottles. Licensee states that meals and snacks are provided by parents and she only provides breakfast to two children at present. LPA reviewed the Healthy Beverages in Child Care with Licensee during today's visit. 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 master bedroom 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. LPA reminded Licensee that the roster that all requested fields on the roster need to be completed. Fire/disaster drill was last conducted on 09/22/2025. LPA obtained copy of children's roster.

Five children’s files were reviewed during today's inspection. Licensee does not have liability insurance for the day care and issues the Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282). LPA reviewed three (3) infant's files and all infants were observed to be missing the 15 minute sleep log.

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.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
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: MOHAMMAD, SURIYA
FACILITY NUMBER: 434416474
VISIT DATE: 01/15/2026
NARRATIVE
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Licensee and assistant files were reviewed for the required forms. All facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee has current Pediatric CPR/First Aid certification which expires on 01/22/2027. Licensee and staff have the required immunization in file for measles and pertussis. Licensee and assistant were unable to provide proof of completed Mandated Reporter Training. Licensee understands the training is mandatory to all Licensees and adults in the home in contact will children and requires renewal every two years. Training website: www.mandatedreporterca.com .

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. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time and a qualified assistant must be present. Licensee understands in absence of a helper her license capacity is reduced to 8 and ratio (age of the children) must be observed.

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.

Licensee is encouraged to visit the Department’s website at https://cdss.ca.gov/inforesources/child-care-licensing to access general updates, resources for providers, regulations, adoptions of new laws, pay annual fees etc.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
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: MOHAMMAD, SURIYA
FACILITY NUMBER: 434416474
VISIT DATE: 01/15/2026
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. Licensee states that she does not have any children that require medication or IMS at this time. For IMS information see PIN 22-02-CCP. 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. Licensee states that an independent driver transports school age children. LPA reminded Licensee that children cannot be left in parked vehicles unattended at any time, the motor vehicles used to transport children shall be maintained in safe operating conditions, and all vehicle occupants must be secured in an appropriate restraint system.

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.

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.

Three Type B deficiencies were cited today on the attached LIC 809D pages. Appeal rights were printed and provided to Licensee.

Exit interview conducted and report was reviewed with the licensee, Suriya Mohammad.

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: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 01/15/2026 03:55 PM - It Cannot Be Edited


Created By: Farida Raja On 01/15/2026 at 03:16 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: MOHAMMAD, SURIYA
FACILITY NUMBER: 434416474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

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
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Based on observation and interview, the licensee did not comply with the section cited above for 3 infants (C3, C4 and C5) which poses a potential health, safety or personal rights risk to persons in care. Infants were observed to be napping in play yards with loose items like blankets and waterproof mats placed on the play yard mattress. LPA also observed a milk bottle and cap inside infant's play yards. Licensee stated that she placed the extra blankets and mats for cushioning to prevent children from injuries. LPA reminded Licensee about safe sleep regulations and provided Licensee with a copy of PIN 20-24-CCP.
POC Due Date: 01/23/2026
Plan of Correction
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Licensee to submit a written plan of correction to LPA by 01/23/2026.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above for herself and assistant which poses a potential health, safety or personal rights risk to persons in care. Licensee and assistant were unable to provide proof of completed Mandated Reporter Training.
POC Due Date: 01/30/2026
Plan of Correction
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Licensee and assistant to provide proof of completed training to LPA by 01/30/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Farida Raja
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 01/15/2026 03:55 PM - It Cannot Be Edited


Created By: Farida Raja On 01/15/2026 at 03:16 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: MOHAMMAD, SURIYA
FACILITY NUMBER: 434416474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above for three infants (C3, C4 and C5) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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Licensee to submit sleep log for all three infants along with a written plan of correction to LPA by 01/30/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Farida Raja
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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