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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415968
Report Date: 09/07/2022
Date Signed: 09/07/2022 01:01:29 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/07/2022 01:01 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
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: 5DATE:
09/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Shahana Khan- LicenseeTIME COMPLETED:
01:15 PM
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On 9/7/21 at 12:24pm, Licensing Program Analyst Briana Plumboy, met with licensee Shahana Khan for an UNANNOUNCED ANNUAL INSPECTION. Present for this inspection was 1 infants and 4 preschool age children, fingerprint clear and associated assistants Milagros Hidalgo and Amelia Medina (Veronica), and licensee's fingerprint clear and associated husband Masudur Khan. The home was toured by LPA Plumboy to conduct a Health and Safety Inspection. This facility currently operates Monday through Friday from 8:00am until 6:00pm.

The home is two stories. 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 are movable play structures located on the right side of the home (little tikes), 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 assistant Amelia Medina CPR and First Aid certificates are current and expires 08/2023. The licensee's mandated reporter training is complete and she received a certification of completion on 09/05/22, Amelia Medina received her certificate of completion on 09/05/22, and assistant Milagros HIldago received her certificate on 9/5/22. The licensee and both assistants 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 3/22/22. The licensee is in ratio today. Licensee provided LPA Plumboy with a copy of her roster. The licensee utilizes Lic. 9227 and is documenting infant safe sleep checks.
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: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
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: 09/07/2022
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Incidental Medical Services (IMS) policy was discussed. 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

Licensee was encouraged to frequently visit our website at ccld.ca.gov for licensing regulations and updates.

Licensee is reminded that ALL assistants, volunteers, and staff, 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



LPA discussed the safe sleep regulations with licensee Shahana Khan and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee Shahana Khan 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.

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

No deficiencies cited during today's inspection. Appeal rights provided and discussed. Exit interview conducted and report was reviewed with licensee Shahana Khan.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC809 (FAS) - (06/04)
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