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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343619143
Report Date: 05/25/2022
Date Signed: 05/25/2022 12:13:45 PM


Document Has Been Signed on 05/25/2022 12:13 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:IRFAN, SHAGUFTAFACILITY NUMBER:
343619143
ADMINISTRATOR:IRFAN, SHAGUFTAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 691-2827
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:14CENSUS: 7DATE:
05/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Shagufta IrfanTIME COMPLETED:
12:30 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 Analysts (LPAs) Gagandeep Singh and Erwin Tjhia met with licensee, Shagfta Irfan, and her husband for a case management inspection related to an incident. Purpose of the inspection was explained.

The licensee self reported that on May 17, 2022, as licensee's husband was preparing to transport a child to the school, a child was did not followed his instructions and ran on the street. Licensee reported that the chid was found at the elementary school, where the child was going to be transported. During today's inspection, LPAs interviewed the licensee. Licensee stated that on the day of incident, the child ran away from licensee's husband and did not followed his instructions to return to the vehicle or home. Per licensee, child's parent and grandparent were contacted. Per licensee, licensee's husband lost the sight of the child and was unable to locate the child. Per licensee, the licensee's husband went to the Barbara Comstock Morse Elementary school, the school child attends, and found that the child was present in child's classroom in the school.

Based on the information collected, it was found that the child was out of supervision and was manage to reach the elementary school without any supervision. A Type “A” violation (see continuation) was issued today. The licensee is informed to provide a copy of the Evaluation Report and the Type “A” Deficiency cited to the parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 shall be maintained in all Children's files. This report and appeal rights were provided and reviewed with the licensee. Notice of Site Visit shall remain posted for 30 days.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep SinghTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
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


Document Has Been Signed on 05/25/2022 12:13 PM - It Cannot Be Edited

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: IRFAN, SHAGUFTA
FACILITY NUMBER: 343619143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/26/2022
Section Cited

1
2
3
4
5
6
7
The licensee shall be present in the home and shall ensure that children in care are supervised at all times. This requirement is not met as evidenced by licensee informed the Department that a child left the supervision and was found at the school. This poses an immediate health and safety risk to children in care.

1
2
3
4
5
6
7

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep SinghTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2