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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415968
Report Date: 10/22/2019
Date Signed: 10/22/2019 11:26:23 AM

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: DATE:
10/22/2019
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Shahana KhanTIME COMPLETED:
12:00 PM
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Licensing Program Analyst Briana Plumboy, met with licensee Shahana Khan on 10/22/19 for an UNANNOUNCED ANNUAL REQUIRED RANDOM INSPECTION. Present for this inspection was 3 infants and 4 preschool age children, as well as fingerprint clear assistants Amelia Medina. This facility was placed on Required Inspections due to the inspection which occurred on 12/21/17. The home was toured to conduct today for a Health and Safety Inspection. This facility currently operates from 8:00am until 6:00pm.

The home is two stories. The home appears to be neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the patio/sun room, family room, downstairs bathroom, and backyard. The OFF LIMIT AREAS will be inaccessible by closed and/or locked doors and visual supervision. The ISOLATION AREA will be the family room. The BACKYARD play area is fenced. There is a play structure located on the right side of the home, and the center of the yard has a garden and toys, and the left side of the yard where the gate opens and leads down a path is off limits to children in care. Licensee is aware children shall not play on the left side of the backyard due to it being off limit and not an approved area. There are toys present during today's inspection. There are no pools, hot tubs or any other bodies of water present in the on limit areas during today's inspection.
The home has two fully charged fire extinguishers, working smoke detector, working carbon monoxide detector, and working telephone.The licensee and present assistant's CPR and First Aid certificates are current and expires 08/2021. The licensee's mandated reporter training is complete and she received a certification of completion on 06/24/18 and her assistants Amelia Medina received her certificate of completion on 06/30/18. The licensee and assistant Amelia Medina have proof of the provider immunization's. The fireplace is screened and tied shut to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 03/25/19. The licensee is in ratio today.
See 809-C for continuance
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2019
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
VISIT DATE: 10/22/2019
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

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

The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. Also, any adults moving into the home must be reported to Community Care Licensing prior to them moving in and all requirements must be met before the person lives in the facility. Licensee was reminded of Departments inspection authority, with our without any notice.

Effective August 1, 2003 California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail. Roster of the children must be properly maintained and fire/disaster drill every six months must be documented.

The licensee was also reminded that baby bouncers, exersaucers, johnny jumpers and similar items are not allowed in licensed day care.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov

For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list



There are no deficiencies cited. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2019
LIC809 (FAS) - (06/04)
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