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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415968
Report Date: 07/24/2019
Date Signed: 07/24/2019 03:40:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:KHAN, SHAHANAFACILITY NUMBER:
013415968
ADMINISTRATOR:KHAN, SHAHANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 489-5350
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:14CENSUS: 9DATE:
07/24/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shanana KhanTIME COMPLETED:
04:00 PM
NARRATIVE
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On 07/24/19, Licensing Program Analysts (LPAs) B.Plumboy and D.Campos met with licensee Shahana Khan for the purpose of an UNANNOUCED CASE MANAGEMENT INSPECTION. Present for this inspection was 4 infants, 5 preschool age children, licensees teenage daughter, as well as fingerprint clear assistant Amelia Medina. This facility was placed on Required Inspections due to the inspection which occurred on 12/21/17.

LPAs Plumboy and Campos toured the facility and observed an infant asleep in a rocker. This is a violation of personal rights. LPAs also observed cleaning supplies underneath the sink in the downstairs bathroom which is an on limit area.

LPA Plumboy provided a copy of Safe Sleep in Child Care brochure, a handout "What Does A Safe Sleep Environment Look Like?," and PIN 19-06-CCP to the licensee

See 809-D for deficiencies cited today. Appeal Rights Given. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and appeal rights provided and discussed.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: KHAN, SHAHANA
FACILITY NUMBER: 013415968
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2019
Section Cited
CCR
102423(a)(2)
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102423(a)(2) Personal Rights. Each child shall be accorded safe, healthful and comfortable accommodations, furnishing and equipment.
This requirement is not met as evidenced by:
Based on observation AN INFANT WAS OBSERVED LAYING ASLEEP INSIDE A ROCKER. THE ROCKER IS A
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Licensee will meet with the 4 infant families to develop a sleep plan for the infants to ensure a safe sleep environment is provided for the infants. Licensee is aware children may not sleep inside rockers.
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RESRAINT FOR NAP TIME AND NOT A SAFE SLEEP ENVIRONMENT WHICH THIS POSES A POTENTIAL HEALTH AND SAFETY RISK TO CHILDREN IN CARE.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Type B
08/02/2019
Section Cited
CCR
102417(g)(4)
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Operation of a Family Child Care Home. Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger to children shall be stored where they are inaccessible to children.
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Licensee removed the cleaning compounds from the drawer during the inspection.
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This requirement is not met as evidenced by:
Based on observation, there are cleaning compounds located inside the bathroom cabinet under the sink. During the inspection, licensee removed the cleaning compounds and made them inaccessible to children. The accessible items posed a potential health and safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019
LIC809 (FAS) - (06/04)
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