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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621889
Report Date: 04/07/2022
Date Signed: 04/07/2022 01:16:04 PM


Document Has Been Signed on 04/07/2022 01:16 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: 9DATE:
04/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Shazia KhanTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tjhia and Licensing Program manager (LPM) Engelman met with the licensee, Shazia Khan, for the case management inspection. Licensing staff toured the facility, observed the care and supervision of the children and reviewed records. An individual, who does not have criminal record clearance, was present and caring for children during today's visit.

Deficiencies were cited on the subsequent pages of this report.


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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin TjhiaTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022
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 2


Document Has Been Signed on 04/07/2022 01:16 PM - It Cannot Be Edited

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: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2022
Section Cited

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(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
This requirement was not met as evidenced by: the adult assistant who provided care and supervision today, does not have criminal record clearance with the Department.
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This presents 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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin TjhiaTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022
LIC809 (FAS) - (06/04)
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