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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416908
Report Date: 01/29/2025
Date Signed: 01/30/2025 11:47:51 AM

Document Has Been Signed on 01/30/2025 11:47 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:KASSAK, NADINEFACILITY NUMBER:
434416908
ADMINISTRATOR/
DIRECTOR:		NADINE KASSAKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 470-0768
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
01/29/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:41 AM
MET WITH:Nadine KassakTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On January 29, 2025 at 8:41 AM, Licensing Program Analysts (LPAs) Marilou Monico and Darnella Barnes conducted an announced Prelicensing Inspection in response to a change of location application. LPAs met with Applicant, Nadine Kassak, and explained to her the purpose of today's inspection. Also present in the home was Applicant's adult daughter. Per Applicant, there are five adults residing in the home: herself, her husband, her mom, and two children.

Days and hours of operation will be Monday - Friday from 8:00 AM to 6:00 PM. Applicant submitted proof of completion in Health and Safety class including Nutrition and Lead Poisoning Prevention. Applicant's Mandated Reporter Training was completed on December 5, 2024. Applicant's immunizations in measles, and pertussis are on file. Applicant's Pediatric CPR/First Aid certifications expire on November 15, 2026. Applicant stated that she will use the Affidavit Regarding Liability Insurance (LIC 282) form to inform parents that she does not carry daycare insurance.

The applicant's husband owns the home and proof of control of property was submitted during the inspection.

LPAs toured the indoor and outdoor areas of the home during today's inspection. LPAs observed: fully charged 3A40BC fire extinguisher, functioning smoke and carbon monoxide detectors. Off limit areas inside the home: kitchen, 2 bedrooms, 1 bathroom, and laundry room. The home is clean and orderly, with heating/air conditioning, and ventilation for safety and comfort. There is sufficient toys, supplies, and equipment for the day care children. Applicant stated that there are no weapons in the home. Off limit areas outside: garage and storage shed. There were no bodies of water observed.

Forms of discipline to be used by Applicant: talking to children and redirection. Cleaning products, toxic agents, medications, and sharp objects were inaccessible to children. LPAs reminded Applicant that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes.
Continuation on next pages:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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: KASSAK, NADINE
FACILITY NUMBER: 434416908
VISIT DATE: 01/29/2025
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Applicant understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed. LPAs informed Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

Applicant, Nadine Kassak, was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 requirements of Assembly Bill(AB) 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPAs discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

LPAs discussed the safe sleep regulations with Applicant 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. LPAs also informed Applicant 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.

LPAs reviewed with Applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

Continuation on next page:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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: KASSAK, NADINE
FACILITY NUMBER: 434416908
VISIT DATE: 01/29/2025
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Incidental Medical Services (IMS) policy was discussed. 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: http://www.ada.gov/childqanda.htm.

PIN 22-02-CCP - Best Practices Related to the Provision of Incidental Medical Services in Child Care Center and Family Care Homes was provided to Applicant.

On this date, January 25, 2025, the California Attorney General - Megan's Law website was searched for information on sex offenders required to register with local law enforcement under California Megan's Law. No registered sex offenders found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Fire clearance was granted on January 21, 2025.

The following items to be sent to Licensing prior to licensure of a Large Family Child Care Home:
1) Photo of barricaded/covered fireplace
2) Photo that the furnace closet located in the hallway is made inaccessible to children
3) Applicant's immunization in flu
Exit interview conducted and report was reviewed with the Applicant, Nadine Kassak.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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