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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621889
Report Date: 05/11/2023
Date Signed: 05/11/2023 04:30:44 PM


Document Has Been Signed on 05/11/2023 04:30 PM - It Cannot Be Edited

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: 12DATE:
05/11/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:12 PM
MET WITH:Shazia KhanTIME COMPLETED:
05:00 PM
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Licensing Program Manager (LPM) Bettina Engelman and Licensing Program Analyst (LPA) Erwin Tjhia conducted a case management inspection to verify corrections of deficiencies cited on 5/1/2023. As licensing staff arrived, licensee was not at facility. LPA and LPM were greeted by the facility staff and were informed that licensee was out. Licensee arrived 20 minutes later.

On 05/1/2023, the facility was cited for two Type A deficiencies for leaving an assistant with 12 daycare children, including 4 infants, and for unsafe backyard for having an opening in the fence leading to the pool area under construction of the house behind the facility.


During today's inspection LPA toured all areas - including the garage and other off-limit areas - and observed 12 children including 3 infants being supervised by two facility staff. One of the staff was CPR certified. LPA also observed the gate in the backyard was completed and was closed during today inspection. However, LPA and LPM noticed the swing at the yard that was not sturdy, as the frame was not anchored into the ground. The swing also had a seat with a broken fabric, creating a hazard to children in care.

LPA reviewed children's files, and observed the signed LIC 9224 Acknowledgment Forms in at least 6 of the 12 files)..

The deficiency cited on 05/01/2023 for Ratio and Capacity can be cleared today. However, the deficiency for unsafe outdoor play area cited on 5/1/2022 cannot be cleared today. During today's inspection, the swing was removed. Civil penalties were assessed for failure to correct this deficiency.

An exit interview was conducted and Notice of Site Visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Appeal rights were discussed and a printed version was given to licensee.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin TjhiaTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
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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