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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417282
Report Date: 10/07/2025
Date Signed: 10/07/2025 12:28:07 PM

Document Has Been Signed on 10/07/2025 12:28 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SIAMER, KHALIDAFACILITY NUMBER:
434417282
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 5DATE:
10/07/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Khalida SiamerTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 10/07/2025, Licensing Program Analyst (LPA), Farida Raja, conducted an unannounced inspection and met with Licensee, Khalida Siamer. LPA informed Licensee of the purpose of today's inspection which is to conduct and annual inspection and to process Licensee's request to increase the capacity of her Family Child Care Home from 8 to 14 children. LPA was granted access to the home by Licensee. Present in the home were licensee, adult daughter/ assistant and 4 children including two infants and two preschool children. One more infant arrived during the inspection. Licensee is operating within the ratio and capacity requirements of the license. Days and hours of operation are Monday to Friday, 8:30 am to 5:00 pm. LPA observed all required posted materials near the front entrance to the home. Per Licensee, three adults and one minor child reside in the home. All adults have criminal record and tuberculosis clearances. Licensee has been licensed as a small Family Child Care Home since 09/07/2022 and thus met the minimum one year experience requirement. Fire Clearance as required to obtain a Large Family Child Care Home License was granted on 10/01/2025.

LPA discussed with Licensee the maximum capacity requirement of a Large Family Child Care Home License. The maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home shall be either:
(1) 12 children, no more than four of whom may be infants; or
(2) more than 12 and up to 14 children if at least one child is enrolled in and attending kindergarten or elementary school and a second child is at least six years of age and there are no more than three infants being cared for during any time when more than 12 children are being cared for.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2025
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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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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SIAMER, KHALIDA
FACILITY NUMBER: 434417282
VISIT DATE: 10/07/2025
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When Licensee has more than 12 and up to 14 children in the home, Licensee must notify the parent using the form LIC9150 “Parent Notification Additional Children in Care." LPA reminded Licensee that when Licensee does not have a Helper, Licensee can only care for up to 8 children at any one time in the home.

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. Furniture was observed in good condition. The home has central heating/cooling, additional fans and ventilation for comfort of children. Off limit areas inside the home: master bedroom, master bathroom, two bedrooms, kitchen, dining room, basement and attached garage. In-use areas include: living room, family room/office and one bathroom. LPA observed a 3A40BC fire extinguisher that was last serviced on 10/01/2025 in the on limit living room. Barricaded fireplace was observed in the family room/office. LPA reminded Licensee that fire extinguishers need to be serviced annually. Working smoke and carbon monoxide detector was observed in the living room. Licensee states that she does not have any weapons or pets in the home. All detergents, cleaning compounds, poisons, medications and other similar items were observed to be stored inaccessible to children. Licensee understands that smoking is prohibited in the home. Kitchen was observed to be made inaccessible from the living room by a swing door and from the family room/office by use of removable child gates. LPA advised Licensee to move all knives and sharps to higher kitchen cabinets. Licensee has 2 play pens and 4 nap mats to be used by children during nap time. Bathroom used by children was in operating condition. Toilets and faucet are clean and operable.

The outdoor space and play equipment were observed to be age appropriate and free of hazards. On limit area outdoors includes the left side area. Back and right side area are off limits to children. There were no bodies of water observed. LPA reminded Licensee to empty all wading pools and water tables immediately after use. Shade was observed to be provided by pergola and trees.

Drinking water is readily available for children in the home via individual water bottles and refilled using store bought water. Licensee states that she provides breakfast and snacks and parents provide lunch. Licensee understands that any food brought from home shall be labeled with each child's name and properly stored or refrigerated.

Licensee stated that the form of discipline used is to talk to child. Licensee states that a child will be isolated on the living room couch, away from other children, if necessary, due to illness or communicable disease.

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

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SIAMER, KHALIDA
FACILITY NUMBER: 434417282
VISIT DATE: 10/07/2025
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LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. Fire/disaster drill was last conducted on 04/08/2025. LPA obtained copy of children's roster.

Four children's file's were reviewed and observed to be complete with the required forms. Infants (C1 and C2) files were observed to be complete with the Individual Infant Sleeping Plan (LIC 9227) and 15-minute sleep logs. Licensee carries daycare insurance and LPA observed a current policy verifying valid coverage.

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 two staff files (Licensee and daughter/assistant) for the required forms. Licensee and assistant were observed to have current Pediatric CPR/First Aid certification and Mandated Reporter Training. Licensee and staff have the required immunization in file for measles, pertussis and statement declining 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 the requirement for Licensee to be present at the facility 80 percent of the hours the facility is in operation and that temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. Licensee understands her capacity options and she understands that she cannot have more than 14 children, once licensed, 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.

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

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SIAMER, KHALIDA
FACILITY NUMBER: 434417282
VISIT DATE: 10/07/2025
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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. The Department will communicate all new information to providers through Provider Information Notices (PINs). Sign up to be notified for new PINs at www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and visit the Department’s website for the latest PINs.

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. Licensee states that she is not administering any medications or IMS to children at this time. 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 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. As a result of today's inspection, there were no deficiencies cited. Exit Interview was conducted, where this report was reviewed with Licensee, Khalida Siamer.

LPA advised Licensee that a Large Family Child Care Home License will be approved upon submission of an updated outdoor sketch (LIC 999A) and final review by the Department.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED FOR 30 CONSECUTIVE 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. Regular updates for licensed providers will be communicated via Provider Information Notice (PIN).
NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC809 (FAS) - (06/04)
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