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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621889
Report Date: 08/07/2019
Date Signed: 08/07/2019 04:15:18 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: 10DATE:
08/07/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Shazia Khan, LicenseeTIME COMPLETED:
04:30 PM
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LPA Denton made unannounced visit to verify correction of deficiencies cited on a previous visit. LPA met with licensee, Shazia Khan.

The following deficiencies were cited during visits conducted on 7/18/19:
102417(g)(10): Operation of a Family Care Home
102417(g)(4): Operation of a Family Care Home
102417(g)(9)(A)(1): Operation of a Family Care Home

Upon arrival to the home LPA observed 10 children under the care and supervision of the licensee and her assistant.

During a visual inspection of the kitchen, LPA did not observe medicines or cleaning compounds to be on the counter or any other accessible area.

LPA did not observe a bouncer chair in the facility.

LPA Denton conducted an audit of facility records to verify that a fire drill had been conducted on 7/19/19.

No Title 22 deficiencies cited during today's visit.

Notice of site visit posted.

Exit interview conducted.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2019
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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