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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417496
Report Date: 09/17/2025
Date Signed: 09/17/2025 09:49:23 AM

Document Has Been Signed on 09/17/2025 09:49 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:NAKAMURA, MEGUMIFACILITY NUMBER:
434417496
ADMINISTRATOR/
DIRECTOR:		MEGUMI NAKAMURAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(858) 610-2780
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/17/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:37 AM
MET WITH:Megumi NakamuraTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA), Syeda Bahar met with the applicant, Megumi Nakamura, to conduct a follow-up pre-licensing visit at her home. Present during this visit were the applicant and her husband. The initial pre-licensing inspection took place on 08/19/2025. The purpose of today’s visit was to inspect the updated daycare areas, both on-limits and off-limits, as well as the infant sleeping equipment and outdoor play area. Prior to this inspection, Applicant submitted an updated facility sketch to the department, and an updated fire clearance was granted on 09/10/2025.

The current updated on-limits areas include: primary bedroom #1, bedroom #4 near the study room, dining room #2, one bathroom (#2) in the hallway, and the outdoor play area. The current updated off-limits areas are: the walk-in closet of the primary bedroom, primary bathroom #1, bedroom #2, exercise room (bedroom #3), study room (bedroom #5), bathroom #3, bathroom #4, laundry room, the combined open kitchen/family dining room (#1), living room, right side yard, and the garage. The off-limits areas are made inaccessible to children by locked doors and barricades.

During today’s inspection, LPA evaluated both the on-limits and off-limits areas, including bedroom #4, which was previously off-limits. The applicant indicated her intention to include bedroom #4 in the on-limits areas, as it will be used as the infant sleeping area. LPA inspected the infant sleeping equipment with Megumi Nakamura and observed that a crib had been installed in bedroom #4. The crib mattress was found to be firm and covered with a fitted sheet that was appropriate, fitting tightly and overlapping the underside of the mattress. LPA observed that the air conditioner condenser in the backyard is barricaded and completely inaccessible to children. Additionally, the applicant removed the barbecue grill with two gas cylinder tanks from the backyard to the right-side yard, which is off-limits and inaccessible to children.

An exit interview was conducted, and the report was reviewed with Megumi Nakamura. LPA advised the applicant that a Large Family Child Care Home License has been approved, effective today, 09/17/2025.
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Syeda Bahar
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2025
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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