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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621889
Report Date: 07/18/2019
Date Signed: 07/18/2019 03:59:38 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, SHAZIAFACILITY NUMBER:
393621889
ADMINISTRATOR:KHAN, SHAZIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 263-9371
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:14CENSUS: 7DATE:
07/18/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shazia KhanTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Justin Denton and Alecia Sifuentes met with Licensee Shazia Khan for an unannounced random annual inspection and toured areas of the home accessible to children in care. Off-limit areas include garage, laundry room, and master bedroom/bathroom. Licensee acknowledged that children may never enter these off-limit areas. The census included 7 children ages three months to nine years. Also present was licensee’s staff, Surjitsing Dhillon. Licensee stated there are no new residents in the home since licensure. All Adult residents have criminal record clearances.

LPA observed current CPR/First Aid certificates which expire in 2021. LPA discussed recent changes in licensing requirements, including the posting of licensing inspection notices and reports and Parent Notification Requirements. LPAs reviewed four children’s files. LPA did not observe documentation of fire drills conducted every six months.

LPA observed that there were no toxic items accessible to children. LPA observed Fireplace which was screened with glass and locked. LPA observed cleaning materials and medication on the kitchen counter. Licensee stated there are no weapons in the home. Fire extinguisher, smoke detector and carbon monoxide detector meet regulation. Toys appear to be safe. The backyard is fenced and gated. LPA observed a wading pool on the property. LPA discussed 100% supervision and that the pool must be emptied when not in use.
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.
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2019
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 5
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, SHAZIA
FACILITY NUMBER: 393621889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2019
Section Cited
HSC
1597.622(a)(1)
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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement was not met as evidence by:
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Licensee stated they shall submit proof of immunization for pertussis, measles, and influenza. Licensee shall maintain documentation of immunization for herself and all employees/assistants in employee files. Proof of correction shall be sent to LPA by POC date:
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LPA did not observe records of staff receiving pertussis, measles or TB test for staff. This is a potential risk to the health and safety of children in care.
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Type B
08/16/2019
Section Cited
CCR
10217(g)(9)(A)(1)
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Operation of a FCCH - All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. This requirement was not met as evidenced by:


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Licensee stated they will conduct a fire drill and document it. Licensee will submit proof to LPA by POC date:
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LPA did not observe documentation of fire drill completed within six months. This is a potential risk to the health and safety of children 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: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5
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, SHAZIA
FACILITY NUMBER: 393621889
VISIT DATE: 07/18/2019
NARRATIVE
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LPA discussed recent changes in licensing requirements, including SB 277 (no longer accepting religious beliefs for immunizations) and SB 792 pertaining to immunization requirements for children and staff - Licensee did not provide proof of staff immunization's.

LPA discussed the new Mandated Reporter Training with licensee. Beginning January 1, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. In addition, existing licensees must meet requirements by March 30, 2018. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/. The training is currently provided in English. LPA did not observe proof of mandated reporter training.

LPA checked facilities fees and confirmed that it is up to date.

LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA advised licensee of their responsibility to stay current in regards to new regulations. LPA also included the email address for the children's advocacy program to stay current on new laws childcareadvocatesprogram@dss.ca.gov.

Title 22 Deficiencies have been cited on the attached LIC 809D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files.

This report was reviewed and discussed with licensee. A notice of site visit and appeal rights were provided.
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5
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, SHAZIA
FACILITY NUMBER: 393621889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2019
Section Cited
HSC
1596.8662(b)(1)
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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated
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Licensee stated they will provide proof of Mandated Reporter Training to LPA by POC date:
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reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement was not met as evidenced by:

LPA did not observe documented Mandated Reporter training.
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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: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5
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, SHAZIA
FACILITY NUMBER: 393621889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2019
Section Cited
CCR
102417(g)(10)
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Operation of a Family Child Care Home: A baby walker is not permitted on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c). This requirement was not met as evidenced by:

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Licensee stated she will remove the prohibited items by the due date.
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LPA observed an infant asleep in a baby bouncer and another bouncer chair in the facility. This is an immediate risk to the health and safety of children in care.
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Type A
07/19/2019
Section Cited
CCR
102417(g)(4)
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Operation of a Family Child Care Home. Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger to children shall be stored where they are inaccessible to children. This requirement was not met as evidenced by:
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Licensee stated they will move all hazardous materials to inaccessible areas by POC date
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LPA observed medicines and cleaning compounds on the kitchen countertop. This is an immediate risk to the health and safety of children 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: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5