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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415968
Report Date: 10/16/2023
Date Signed: 10/16/2023 02:48:07 PM


Document Has Been Signed on 10/16/2023 02:48 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
OAKLAND SOUTH EAST, 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: 10DATE:
10/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shahana Khan- LicenseeTIME COMPLETED:
03:00 PM
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On 10/16/23, Licensing Program Analysts Briana Plumboy and Randall Dunevant met with licensee Shahana Khan for an UNANNOUNCED ANNUAL INSPECTION. Present for this inspection was 4 infants and 6 preschool age children, fingerprint clear and associated assistant Amelia Medina (Veronica), and licensee's fingerprint clear and associated husband Masudur Khan. The home was toured 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 08/2025. The licensee's mandated reporter training is complete and she received a certification of completion on 08/23/23, and Amelia Medina received her certificate of completion on 8/28/23. The licensee and assistant present 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 6/12/23. The licensee is in ratio today. 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: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: KHAN, SHAHANA
FACILITY NUMBER: 013415968
VISIT DATE: 10/16/2023
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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 encouraged to frequently visit our website at ccld.ca.gov for licensing regulations and updates.

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

Family Child Care Homes 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.

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.

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: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: KHAN, SHAHANA
FACILITY NUMBER: 013415968
VISIT DATE: 10/16/2023
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The licensee provided proof of control of property.

LPA discussed the safe sleep regulations with 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.

During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility.

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: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC809 (FAS) - (06/04)
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