<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343617830
Report Date: 01/10/2022
Date Signed: 01/10/2022 12:57:02 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, SAMINAFACILITY NUMBER:
343617830
ADMINISTRATOR:KHAN, SAMINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 688-3642
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:14CENSUS: 6DATE:
01/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Samina & Iqbal KhanTIME COMPLETED:
01:10 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) Gagandeep Singh met with licensee, Samina Khan, and her husband, Iqbal Khan, for an annual inspection. The purpose of the inspection was explained. Licensee lives in a single story home. Present, there are six children in care with licensee and her husband. All adults living or working in the home have criminal background check on file. Licensee is operating within the capacity of this date. Licensee provides day care from Monday to Friday between 6:30 AM to 6 PM.

LPA inspected the day care areas with the licensee. Day Care Areas: Family room, small room on right side of main entrance, Kitchen, Dining area, Living room, Hallway, Bathroom in hallway, Sunroom and Backyard. Off limit areas: All bedrooms, Laundry room and Garage. There is no pool, spa or any other body of water in the house. As per licensee, there is no firearm or weapon in the house. All the cleaning supplies, poisons and other chemicals are stored inaccessible to the children. Fireplace is barricaded. The house is in good repair and free of hazards with proper temperature and ventilation. There is carbon monoxide detector, smoke detector, fully charged fire extinguisher and working telephone available in the house. Knives are stored in the high cabinet in the kitchen. There is a variety of age appropriate toys in the house. Licensee has sufficient amount of playards in the house for the infants.

LPA reviewed the facility records. LPA observed licensee has License and other required documents posted in the child care areas. Licensee has record of training of preventive health and CPR card valid until June 2023. LPA remind the licensee to conduct the fire or emergency drills at least once every six months and drills must be logged. Licensee has a log in place and per log, last drill was conducted on December 12, 2021. LPA also reviewed the present children's record. LPA reviewed the identification and emergency information form for every child for proper names and numbers filled. Licensee has record of immunization of each child in care. Licensee has well maintained children roster on file.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep SinghTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 01/10/2022
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
26
27
28
29
30
31
32
Continuation from previous page ........

Licensee is aware that all staff is required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. LPA observed licensee has completion certificate of her and her husband’s on file and per certificate, the training is valid until June 2022. LPA discussed the safe sleep regulations and provided a copy of PIN 20-24-CCP to licensee.

LPA reminded the licensee that all adults, 18 years and older living in the home, helper or assistant must have criminal record clearance and must be associated to the facility prior to having any contact with children in care. Failure to do so could result in an immediate civil penalty of $100.00 each day.

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 encourage the licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.



No deficiencies are cited today. The copy of this report is reviewed and provided to the licensee. Notice of site visit is posted and shall remain posted for next 30 days.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep SinghTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2