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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 393621889
Report Date: 03/08/2021
Date Signed: 03/08/2021 03:36:48 PM



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
02/26/2021 and conducted by Evaluator Chayntel Hunter
PUBLIC
COMPLAINT CONTROL NUMBER: 53-CC-20210226132737
FACILITY NAME:KHAN, SHAZIAFACILITY NUMBER:
393621889
ADMINISTRATOR:KHAN, SHAZIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 263-9371
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:14CENSUS: 4DATE:
03/08/2021
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Licensee, Shazia KhanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Licensee uses inappropriate forms of discipline
INVESTIGATION FINDINGS:
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The facility was contacted via FaceTime video call due to the recent COVID19 State of Emergency. Licensing Program Analyst (LPA) Chayntel Hunter spoke with Licensee, Shazia Khan to deliver the findings of the complaint investigation regarding the above allegation. In lieu of Licensee's signature, LPA Hunter is emailing the report with a read receipt request.

During the course of the investigation, LPA Hunter conducted interviews, and obtained information pertaining to the allegation. It was alleged that the Licensee uses inappropriate forms of discipline. Interviews conducted revealed that the Licensee uses naptime as a form of discipline and uses a raised tone of voice with children in care. LPA also received statements that revealed that the Licensee used physical contact as a form of discipline.

Report continues on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
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 53-CC-20210226132737
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: KHAN, SHAZIA
FACILITY NUMBER: 393621889
VISIT DATE: 03/08/2021
NARRATIVE
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Licensee stated that although she has used a raised tone of voice with children, she did not feel sending the children to take a nap was considered a form of disciple and stated she does not use physical contact as a form of discipline. LPA reviewed Title 22 regulations and personal rights with the Licensee.

Based on the interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Title 22 regulations are being cited on the attached 9099-D page.

Upon receipt of Type A citations, licensee shall post and provide copies of the LIC 9099-D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Licensee must also keep the signed LIC 9224, acknowledging receipt of LIC 9099-D in each child's file. An exit interview was conducted with the Licensee. Appeal rights were printed and provided. Notice of Site Visit was provided and must remain posted for 30 days.
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
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
02/26/2021 and conducted by Evaluator Chayntel Hunter
PUBLIC
COMPLAINT CONTROL NUMBER: 53-CC-20210226132737

FACILITY NAME:KHAN, SHAZIAFACILITY NUMBER:
393621889
ADMINISTRATOR:KHAN, SHAZIAFACILITY TYPE:
810
ADDRESS:239 ORIOLE LANETELEPHONE:
(209) 263-9371
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:14CENSUS: 4DATE:
03/08/2021
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Licensee, Shazia KhanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
Uncleared staff
Due to a lack of supervision a child was injured while in care
INVESTIGATION FINDINGS:
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The facility was contacted via FaceTime video call due to the recent COVID19 State of Emergency. Licensing Program Analyst (LPA) Chayntel Hunter spoke with Licensee, Shazia Khan to deliver the findings of the complaint investigation regarding the above allegations. In lieu of Licensee's signature, LPA Hunter is emailing the report with a read receipt request.

During the course of the investigation, LPA Hunter conducted interviews, and obtained information pertaining to the allegations. It was alleged that there was an uncleared staff member (S1) at the facility. Although it was determined that S1 was cleared, LPA received statements that another staff member (S2) has been used to supervise children in care.


Report continues on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 53-CC-20210226132737
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: KHAN, SHAZIA
FACILITY NUMBER: 393621889
VISIT DATE: 03/08/2021
NARRATIVE
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Although Licensee stated S2 was not left alone to supervise children in care, LPA received conflicting statements regarding S2 and was unable to determine if S2 was providing care and/or left alone to supervise children in care. Based on conflicting statements about S2, the allegation was found to be UNSUBSTANTIATED.

It was also alleged that a child was injured in care, due to a lack of supervision. Based on the information obtained throughout the course of the investigation, LPA was unable to determine whether there was a lack of supervision which resulted in a child being injured. Given the severity of the injury, the Department felt that the allegation could not be dismissed, therefore the allegation was found to be UNSUBSTANTIATED.

LPA Hunter determined that the complaint was found to be UNSUBSTANTIATED, meaning 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. An exit interview was conducted with the Licensee. Appeal rights were printed and provided. Notice of Site Visit was provided and must remain posted for 30 days.
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 53-CC-20210226132737
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: KHAN, SHAZIA
FACILITY NUMBER: 393621889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2021
Section Cited
CCR
102423(a)(4)
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Personal Rights: 102423 (a) Each child... shall have certain rights that shall not be waived or abridged by the licensee... (4) To be free from corporal or unusual punishment... or other actions of a punitive nature. This requirement was not met as evidenced by:
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Licensee will watch personal video training video on CCLD website. Licensee stated she will not use naptime as a form of punishment and will be more mindful of her tone of voice with children.
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Based on interviews conducted it was revealed that the Licensee uses naptime as a form of discipline and uses a raised tone of voice with children in care. LPA also received statements that the Licensee used physical contact as a form of discipline. This is an immediate health and safety risk to 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: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5