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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417496
Report Date: 08/19/2025
Date Signed: 08/19/2025 03:22:08 PM

Document Has Been Signed on 08/19/2025 03:22 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:NAKAMURA, MEGUMIFACILITY NUMBER:
434417496
ADMINISTRATOR/
DIRECTOR:		MEGUMI NAKAMURAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(858) 610-2780
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
08/19/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:02 PM
MET WITH:Megumi NakamuraTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA), Syeda Bahar, met with Licensee, Megumi Nakamura for an announced Pre-Licensing Inspection, for a change of location. Present for this inspection are Licensee, and one fingerprint cleared adult, Shinji Nakamura. The home was toured to conduct a Health and Safety Inspection. Days and hours of operation are from 7:00 AM to 7:00 PM, Monday to Friday. The home is single story and it consists of a living room, dining room, kitchen, four (4) bedrooms, four (4) bathrooms, study/office, garage, backyard, 2 side yards. The home is neat and clean with heating and ventilation for safety and comfort.

On-limits area: Dining room, Primary bedroom, Backyard, one bathroom (3) in the hallway.
Off-limits area: Living room, kitchen, study/office, 3 bedrooms, 3 bathrooms, garage, right side yard
Isolation area: Study/office

The outdoor play area is free from defects or dangerous conditions and is fenced. There are ample age-appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs, or any other bodies of water. All hazardous materials and toxins are kept out of the reach of children, and it was observed that there are no toxins or hazardous items accessible today. Licensee states that any poisons are stored in kitchen cabinet which is off-limits. LPA reminded Licensee that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes. The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The Licensee's CPR and First Aid certificate is current and expires in 8/16/2027. Licensee completed the Mandated Reporter Training for Child Care Providers on 12/02/2023 and a copy of the certification is on file.
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NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Syeda Bahar
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2025
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 5
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: NAKAMURA, MEGUMI
FACILITY NUMBER: 434417496
VISIT DATE: 08/19/2025
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Licensee was reminded of Mandated reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. A copy of the Licensee's immunization is on file. Per Licensee, there are no firearms in the home.

Licensee states that she will not administer any medication to the children at this time. Licensee states that a child will be isolated in the study/office room, if necessary, due to illness or communicable disease. Licensee has a First Aid kit with a touch-less thermometer in the home. Also discussed with Licensee the requirements for reporting suspected child abuse, unusual incidents/injuries, and heat related illnesses. The Licensee was reminded that California law requires Licensees to report unusual incidents and/or injuries to children in care, to the child's parents, and to Community Care Licensing Division (CCLD) by the next business day by phone. Within seven (7) days from the incident, Licensee must submit the Unusual Incident/Injury form (LIC 624B) to CCLD. Licensee was reminded that any structural changes or additions to the home must be reported to CCLD as well. Children’s Roster must be properly maintained, and fire/disaster drills must be conducted every six (6) months and documented.

Forms of discipline to be used by Licensee are redirecting and talking. Licensee understand that children's personal rights should not be violated, including but not limited to, no corporal punishment, children are treated with dignity, receive safe, healthful, and comfortable accommodations, interference with eating, intimidation, or other actions of a punitive nature. The Licensee provided proof of control of property to the Department prior to today’s inspection and a copy of the document is on file. Licensee does not have liability insurance at this time and will issue Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282) to all enrolling families until she obtains liability insurance in the future.

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) or (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.

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NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Syeda Bahar
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
Page: 3 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: NAKAMURA, MEGUMI
FACILITY NUMBER: 434417496
VISIT DATE: 08/19/2025
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Licensee, Megumi Nakamura 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.

LPA reviewed with the Licensee, 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. Pre-licensing Entrance Checklist – Family Child Care Homes (LIC 9280) was provided to the Licensee.

LPA discussed the safe sleep regulations with Licensee, Megumi Nakamura, and discussed the Child Care Licensing Safe Sleep web page athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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.



On this date, 08/18/2025, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been 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.

Licensee 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.

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NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Syeda Bahar
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: NAKAMURA, MEGUMI
FACILITY NUMBER: 434417496
VISIT DATE: 08/19/2025
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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 platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

During today's inspection LPA observed there is an air conditioner condenser unit and a Bar Be Que (BBQ) Grill with two gas cylinder tanks in the backyard. Licensee was advised to install a barricade around the air conditioner condenser and send a picture to LPA Syeda. Licensee was also advised to move BBQ Grill and gas cylinders from the backyard. Additionally, Licensee was advised to place the infant crib in the day care on limit area.

Exit interview conducted and report was reviewed with the Licensee, Megumi Nakamura. LPA advised the Licensee that a Large Family Child Care Home license will be approved pending Licensing Program Manager’s review.
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Syeda Bahar
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
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