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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343622322
Report Date: 02/27/2020
Date Signed: 02/27/2020 08:36:51 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2020 and conducted by Evaluator Mai Lor
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20200131132309
FACILITY NAME:KHANI, ANGELAFACILITY NUMBER:
343622322
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
02/27/2020
UNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Angela KhaniTIME COMPLETED:
08:50 AM
ALLEGATION(S):
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Uncleared adults residing and/or providing care and supervision to children
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Mai Lor and Christopher Bello conducted a follow-up complaint investigation at the above facility and met with licensee Angela Khani. LPAs observed six day care children. During the investigation, LPA Lor conducted a health and safety inspection, interviewed parents, licensee, and day care children, and obtained pertinent documentation. It was alleged that there were uncleared adults residing and/or providing care and supervision to children. Interviews revealed that the licensee’s adult nephew was residing in the home from July 2018 through March 2019 without being associated to the facility. The adult nephew had a criminal clearance; however, the individual was not associated to facility until February 2019.

Based on the above, the above allegation is substantiated meaning the preponderance of evidence has been met.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai LorTELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 03-CC-20200131132309
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/27/2020
NARRATIVE
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Title 22 deficiency cited on the subsequent page of this report. Civil penalty assessed in the amount of $100 for uncleared adult residing in the home.

Type A acknowledgement forms are to be signed by current parent of the facility and new parents for the next twelve months. LIC 9224 and Appeal Rights were provided. An exit interview was conducted. A Notice of Site Visit posted which must remain posted for 30 days.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai LorTELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2020 and conducted by Evaluator Mai Lor
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20200131132309

FACILITY NAME:KHANI, ANGELAFACILITY NUMBER:
343622322
ADMINISTRATOR:KHANI, ANGELAFACILITY TYPE:
810
ADDRESS:4606 WESTLAKE PARKWAYTELEPHONE:
(916) 544-9437
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:8CENSUS: 6DATE:
02/27/2020
UNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Angela KhaniTIME COMPLETED:
08:50 AM
ALLEGATION(S):
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Licensee has a second job and is not in the facility 80% of the time
Licensee interfering with inspection authority.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Mai Lor and Christopher Bello conducted a follow-up complaint investigation at the above facility and met with licensee Angela Khani. LPA observed six day care children. During the investigation, LPA Lor conducted a health and safety inspection, interviewed parents, licensee, and day care children, and obtained pertinent documentation.

It was alleged the licensee has a second job and not present in the facility 80 percent of the time. Licensee acknowledged that she is an event planner on the weekends and stated that it does not interfere with day care hours of operation. Interviews also revealed that the licensee’s adult daughter is the substitute day care provider when the licensee is absence from the facility; however, the frequency and duration of the licensee’s absence from the facility is undetermined.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai LorTELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 03-CC-20200131132309
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/27/2020
NARRATIVE
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 It was also alleged the licensee is interfering with inspection authority. Licensee denied instructing anyone to not open the door for licensing. Statement in interviews were inconsistent and does not corroborate the allegation. Based on the above, the allegations are unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur at the facility, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and appeal rights provided. A Notice of Site Visit was posted.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai LorTELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 03-CC-20200131132309
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2020
Section Cited
CCR
102370(d)(2)
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Request a transfer of a criminal record clearance as specified in Section 102370(j). This requirement is not met as evidenced by:
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Licensee's adult nephew is no longer residing in the home. No further POC is needed.
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Based on interview and record review, licensee’s adult nephew had a criminal record clearance but was not associated to the facility, which poses an immediate health and safety risk to persons in care.
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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: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai LorTELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 5