343617830-11-15-2019-03-CC-ESIA-BHXSAV-20191115124259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343617830
Report Date: 11/15/2019
Date Signed: 11/15/2019 12:43:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME:	KHAN, SAMINA		FACILITY NUMBER:	343617830
ADMINISTRATOR:	KHAN, SAMINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 688-3642
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	14	CENSUS: 10	DATE:	11/15/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Samina Khan		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Elvira Sierra met with the licensee, Samina Khan for the purpose of an unannounced annual random inspection. The licensee's husband was also present during the inspection. All individuals subject to criminal background review have obtained a criminal record clearance. Present in the facility were 9 children (2 infants, 6 preschool, 2 school age). One school age child was Licensee's grandchild. Facility hours of operation are M-F from 06:30 AM to 06:00 PM. A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include; All bedrooms and left side of the yard. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. There are no bodies of water on the premises. Toxic and hazardous items are inaccessible to children. Safety latches are in use on some kitchen cabinets and bathroom cabinets and drawers. The applicant understands that she must ensure the safety latches are not broken. A random sample of children’s files were reviewed. Emergency information and required immunization records were on file. LPA observed a current roster and fire drills are conducted at least once every six months. The licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Updated Pediatric First Aid/ CPR was verified and expires on 06/2021. AB 1207 Mandated Reporter Training was verified for Licensee and Licensee's husband. This provider is currently not providing IMS services to children in care. 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. Report continues on 809-C.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2019

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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: KHAN, SAMINA	FACILITY NUMBER: 343617830
	VISIT DATE: 11/15/2019

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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 verified the annual fees are current. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the licensee can request to be added to the distribution list to receive Quarterly Updates. LPA provided and discussed the Safe Sleep in Child Care and Effects of Lead Exposure brochures.

This facility evaluation report was reviewed and discussed with the licensee. A Notice of Site Visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.

This report was reviewed and discussed with Licensee. LPA conducted an exit interview. Based upon today’s inspection, No Title 22 deficiency were cited.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2019

LIC809 (FAS) - (06/04)

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