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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100612
Report Date: 06/01/2021
Date Signed: 06/01/2021 09:03:46 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:KOHISTANI, HABIBULLAH & PARWIN FAMILY CHILD CAREFACILITY NUMBER:
376100612
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 1DATE:
06/01/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:34 AM
MET WITH:Habibullah & Parwin KohistaniTIME COMPLETED:
08:50 AM
NARRATIVE
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On June 1, 2021 at 8:34AM, Licensing Program Analyst (LPA) Nancy Diaz conducted an unannounced case management inspection. This inspection was conducted virtually via Zoom meeting due to COVID-19 pandemic restriction. This inspection is in reference to licensee's request for an increase of capacity. A tour of the home was conducted with Mr. Kohistani. The following areas are accessible to children: living room, family room, dining, kitchen, downstair bathroom and back fenced yard. Observed present today was one child in care.

Licensee maintains a regulation-size fire extinguisher. Smoke detector was tested today.

Fire Marshall clearance was received on 4/28/2021 from El Cajon Fire Department. Fire Marshall has granted capacity up to 14 children.

Type B deficiency was cited today. Type B violation if not corrected, is a potential risk to the health, safety, or personal rights of children in care.

An exit interview was conducted with the applicant. Appeal Rights (LIC9058) will be sent along with the report (LIC809) via e-mail to the Applicant. Applicant will confirm receipt of this report via e-mail and the reply of confirmation will serve as the signature acknowledging these rights. The Notice of Site Visit (LIC9213) must remain posted for 30 days
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Nancy DiazTELEPHONE: (619) 767-2207
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: KOHISTANI, HABIBULLAH & PARWIN FAMILY CHILD CARE
FACILITY NUMBER: 376100612
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2021
Section Cited

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(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.
(1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.
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This requirement was not met as evidenced by LPA's review of children's records.
Licensee failed to transfer the immunization record to form PM 286.
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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: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Nancy DiazTELEPHONE: (619) 767-2207
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2021
LIC809 (FAS) - (06/04)
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