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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411364
Report Date: 08/14/2025
Date Signed: 08/14/2025 01:39:16 PM

Document Has Been Signed on 08/14/2025 01:39 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:YAMASHITA, MICHELLEFACILITY NUMBER:
434411364
ADMINISTRATOR/
DIRECTOR:		YAMASHITA, MICHELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 559-7595
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
08/14/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:36 AM
MET WITH:Michelle YamashitaTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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On 08/14/25 at 8:36AM, Licensing Program Analysts (LPA) Jaime Gonzales and Licensing Program Manager (LPM) Belinda Devall conducted an unannounced annual random inspection. LPA and LPM were granted access to the home by the licensee Michelle Yamashita. Upon arrival, there were children 1 infant and 1 staff present. In addition, present during the time of inspection were the licensee’s 2 adult children and husband. During the inspection an additional 2 staff and 11 other children (3 infant and 8 preschoolers) arrived by 10:47AM. Facility is compliant with the home license capacity and ratio requirements.

The home was toured to conduct a Health and Safety Inspection. LPA observed all required postings near the entrance to the home. Days and hours of operation are from Mon.-Fri. 8:30AM-5:30PM. The ages of the children to be served are 0-12 years old. The home is neat and clean with heating and ventilation for safety and comfort. The on-limit areas of the home are: Front yard, driveway, kitchen, living room, dining room, office, bedroom, master bedroom, hall bathroom and grass and concrete area of the backyard. The off-limit areas are: master bathroom, garage, 2 sheds, and left side of the backyard when facing the home. Off-limit areas are inaccessible by closed and/or locked doors and with visual supervision. During the inspection, LPA observed the top drawer to the left of the sink had nails/screws and in a drawer under the sink were facial cosmetic masks that state keep out reach of children which is accessible but not detrimental to the health and safety of children in care. The licensee removed the hazardous items during the inspection.

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NAME OF LICENSING PROGRAM MANAGER: Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST: Jaime Gonzales
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2025
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: YAMASHITA, MICHELLE
FACILITY NUMBER: 434411364
VISIT DATE: 08/14/2025
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 The outdoor backyard and front yard play area is free from defects or dangerous conditions and is fenced. The licensee provides 100% supervision while in the outdoor play area. There are ample age-appropriate toys that appear to be safe and in good condition. There are no bodies of water. The isolation area is in the dining room or master bedroom. Licensee states that any poisons are stored in a locked cabinet. Per Licensee, there are no firearms in the home. LPA reminded Licensee that smoking, sleep sacks, baby walkers, and similar items are not allowed in Family Child Care Homes.

The home has a fully charged (2A10BC) fire extinguisher purchased on 01/09/2025, working smoke detector/carbon monoxide detector, and working telephone. The Licensee CPR and First Aid certificate is current and expires 08/09/2027. Licensee completed the Mandated Reporter Training for Child Care Providers and expires on 04/25/26 and a copy of the certification is on file. 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 at least every six months and was last conducted on 03/31/2025. Personnel records are available for review. One staff had expired mandated reporter training on 08/11/2025 and LPA observed that staff enrolled in the training during the time of inspection. Child’s records are available for review and 1 child file was missing updated immunization record. Licensee contacted parents for updated immunization record during the inspection. LPA reviewed 4 children's file. 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, including the infant’s sleeping position and documentation of 15-minute checks while sleeping.

All cribs or play yards meet the safety standards. The mattresses in the crib or play yards are firm and covered with a fitted sheet that is appropriate, fits tightly, and overlaps the underside of the mattress. 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.

Forms of discipline to be used by Licensee are talking with the child and natural consequences. Licensee understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, interference with eating, sleeping, intimidation, or other actions of a punitive nature. Children are treated with dignity, and receive safe, healthful, and comfortable accommodations.

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NAME OF LICENSING PROGRAM MANAGER: Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST: Jaime Gonzales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
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: YAMASHITA, MICHELLE
FACILITY NUMBER: 434411364
VISIT DATE: 08/14/2025
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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.

During the exit interview, 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 08/12/25.

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.

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-care-licensing/subscribe and select the Child Care option to receive email communication.

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NAME OF LICENSING PROGRAM MANAGER: Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST: Jaime Gonzales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
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: YAMASHITA, MICHELLE
FACILITY NUMBER: 434411364
VISIT DATE: 08/14/2025
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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.

No deficiencies are issued during today's inspection.

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


Appeal Rights provided.
Exit interview conducted and report was reviewed with the Licensee, Michelle Yamashita.
NAME OF LICENSING PROGRAM MANAGER: Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST: Jaime Gonzales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
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