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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444405980
Report Date: 03/28/2025
Date Signed: 03/28/2025 01:37:14 PM

Document Has Been Signed on 03/28/2025 01:37 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:KISHI, SHARONFACILITY NUMBER:
444405980
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 2CENSUS: 0DATE:
03/28/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Sharon KishiTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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At 11:30, Licensing Program Analyst (LPA) Angela Luz met with Licensee Sharon Kishi to conduct an unannounced annual RANDOM inspection. Present for this inspection was fingerprint cleared spouse. The home was toured to conduct a Health and Safety Inspection. Days and hours of operation are Monday – Friday 7:30-5:00.

Facility: The OFF LIMIT AREAS are all bedrooms, primary bathroom, laundry room, garage, and backyard. Off limit areas are inaccessible by closed and/or locked doors and visual supervision. The home is neat and clean with heating and ventilation for safety and comfort. The ISOLATION AREA is the living room. The backyard is OFF LIMITS due to a creek behind the property. Licensee states that the city did not allow them to build fencing to prevent access from children in care. All outdoor play is conducted in the front yard that is secured by gates. There is one gate that has access to the backyard. There have been no changes from the areas previously identified as OFF LIMITS or alterations to existing building or grounds. There are no bodies of water other than the creek behind the property. Most hazardous materials and toxins are kept out of the reach of children. LPA observed cleaning compounds underneath the daycare bathroom sink. LPA reminded that hazardous materials and toxins shall be kept out of the reach of children. LPA observed knives in a kitchen drawer. Licensee states that when there are children in care, they close the child gate leading to the kitchen, which prevents access to the kitchen drawers. Licensee states that there are no firearms in the home. The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. LPA reminded that fire extinguishers should be serviced once a year. Licensee made an appointment to get the fire extinguisher serviced. There are two staircases in the home. One staircase has a barricade and the other does not. LPA reminded that stairs should be barricaded when there are children younger than five years old are in care. ***Page 1 of 4***
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2025
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 9
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: KISHI, SHARON
FACILITY NUMBER: 444405980
VISIT DATE: 03/28/2025
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Care and Supervision: There are ample age-appropriate toys that appear to be safe and in good condition. LPA observed 1 play yard. The play yard does not hinder entrance or exit to and from the space where infants are sleeping. LPA observed a fitted sheet on the mattress pad and blankets between the mattress pad and fitted sheet. The owner’s manual for the play yard states to only use the mattress pad provided. Licensee took out the blankets between the fitted sheet and mattress pad. Each infant’s bedding is used for them only and cleaned weekly or before use by another infant. There are no loose articles and objects, bumper guards or objects hanging above or attached to the side of the cribs or play yards. Licensee understands Infant Safe Sleep requirements.

Licensee uses redirection, talking with the child, and time out as forms of discipline. LPA advised that best practice for time outs is one minute per year of age. Licensee understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, interference with eating, intimidation, or other actions of a punitive nature. Children are treated with dignity, receive safe, healthful, and comfortable accommodations.

Records: The Licensee CPR and First Aid certificate expired on 7/19/24. LPA observed an enrollment receipt that Licensee will attend an in-person class on 4/5/25. Licensee Mandated Reporter Training for Child Care Providers is current and expires 3/20/25. 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. The Licensee conducts and documents fire and disaster drills every six months, last drill was on 2/28/25. A current copy of the facility roster was viewed, and a copy was obtained. Licensee states they have liability insurance and issues Affidavit Regarding Liability Insurance (LIC 282) to enrolled families as a precaution. Entrance checklist for Family Child Care Home was provided and licensee was reminded of documents to be posted in a prominent, publicly accessible area of the facility.

LPA reviewed two (2) children files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization records. Each infant under 12 months of age has an Individual Infant Sleeping Plan maintained in the file signed and dated by the infant’s authorized representative. Documentation of infant sleep checks every 15 minutes that notate any signs of distress are maintained in their file. C2 was missing LIC 995A. ***Page 2 of 4***
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
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: KISHI, SHARON
FACILITY NUMBER: 444405980
VISIT DATE: 03/28/2025
NARRATIVE
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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.

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.

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-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.

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: https://www.ada.gov/resources/child-care-centers/.

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.

***Page 3 of 4***
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC809 (FAS) - (06/04)
Page: 4 of 9
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: KISHI, SHARON
FACILITY NUMBER: 444405980
VISIT DATE: 03/28/2025
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During the exit interview, the LICENSEE, Sharon Kishi, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Megan's Law was checked on 2/18/25.

No deficiencies are issued today.
4 advisory notes are issued.
  • Barricade staircases when children less than 5 years old are present
  • Keep hazardous materials out of the reach of children
  • CPR/1st Aid needs to be renewed every two years
  • Keep the bottom portion of LIC 995A in children's files.

Appeal rights were provided.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Sharon Kishi.

***Page 4 of 4***
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Angela Luz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC809 (FAS) - (06/04)
Page: 5 of 9