343622322-10-15-2019-03-CC-JKEY-BGYSDK-20191015134717

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343622322
Report Date: 10/15/2019
Date Signed: 10/15/2019 01:47:22 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:	KHANI, ANGELA		FACILITY NUMBER:	343622322
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 5	DATE:	10/15/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Angela Khani		TIME COMPLETED:	02:00 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 Analysts (LPAs) Joleen Kenney and Tanya Washington met with the licensee, Angela Khani, for the purpose of an unannounced annual/random inspection. All individuals subject to criminal background review have obtained a criminal record clearance. Hours of operation for the facility are Monday-Friday, 6 AM to 6 PM. During today's inspection LPAs observed 3 infants and 2 preschool age children supervised by the Licensee and her adult daughter. A health and safety inspection was conducted in all areas accessible to children. The Licensee requested to make bedroom #1 located downstairs that was previously identified as off limits as an on limit area and accessible to children. LPA Kenney inspected bedroom #1 and determined that the room was safe for children. Off-limits areas includes the entire upstairs, laundry room and garage. Licensee acknowledged that children must never enter these areas. LPA observed the required postings, a working phone, fire extinguisher, and smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. There are no accessible bodies of water at the home. Toxic and hazardous items are inaccessible to children. The fireplace is appropriately barricaded to prevent access by children. The fenced backyard is accessible for children to play. Licensee understands that 100% supervision is required in unfenced areas. Children’s files were reviewed. LPA observed immunization records and signed Family Child Care Home Notification of Parents' Rights in children's files. LPA discussed the requirement to maintain a current children's roster. Fire and disaster drills were discussed.. The licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu were verified. Licensee has a in person EMSA CPR and First Aid certification that expires on 8/12/2020. Licensee has completed the Mandated Reporter Training. Licensee understand that the training is required to be completed once every two years and the training is accessible at www.mandatedreporterca.com. Report continues on 809-C.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Joleen Kenney	TELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019

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: KHANI, ANGELA	FACILITY NUMBER: 343622322
	VISIT DATE: 10/15/2019

NARRATIVE

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This Licensee does not currently provide 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.

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/childqanda.htm.

LPA verified that the annual fees are current. 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. The licensee's signature on this form acknowledges receipt of this form.

In the areas that were evaluated, no deficiencies were observed or cited during todays visit.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Joleen Kenney	TELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019

LIC809 (FAS) - (06/04)

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