393621889-4-7-2022-53-CC-BENN-CDDUMR-20220411154246

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 393621889
Report Date: 04/07/2022
Date Signed: 04/07/2022 01:26:47 PM

Substantiated

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
03/29/2022 and conducted by Evaluator Erwin Tjhia

PUBLIC

COMPLAINT CONTROL NUMBER: 53-CC-20220329153113

FACILITY NAME:	KHAN, SHAZIA		FACILITY NUMBER:	393621889
ADMINISTRATOR:	KHAN, SHAZIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 263-9371
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	14	CENSUS: 9	DATE:	04/07/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Shazia Khan		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

License: Ratio and Capacity

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Erwin Tjhia and Licensing Program Manager (LPM) Bettina Engelman met with licensee, Shazia Khan to open the above complaint investigation. LPA toured the facility, observed the care and supervision of children, and conducted interviews.

According to the complaint, licensee is operating out of ratio and capacity requirements. When LPA and LPM arrived for today’s visit, the licensee was alone with 9 children including 3 infants and no school age children. An adult assistant (S1) arrived, as the licensing staff entered the facility. Licensee explained that a different assistant (S2) worked with her this morning between 7 am to 9 am. She called S1 to come and support her at 10 am. Licensee was out of ratio between 9 am to 11:15 am today. Licensee explained that she usually has enough staff, but that today no other assistants were available to work.

Report continues on subsequent form 9099-C and 9099-D

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin Tjhia	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 53-CC-20220329153113

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: 04/07/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on LPA and LPM observation and the admission by licensee, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Title 22 deficiencies were cited and must be corrected by the due date. Failure to correct deficiencies will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected. Appeals rights were discussed.

Notice of Site Visit posted. An exit interview was conducted in which the report was reviewed and discussed with licensee.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin Tjhia	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 53-CC-20220329153113

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: 04/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/08/2022 Section Cited CCR 102416.5e	1 2 3 4 5 6 7	(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).	1 2 3 4 5 6 7	Licensee acknowledged that small Family child Care Home ratios must be adhered to, when she has no assistant present. Licensee shall submit a written statement on how to comply with ratio and capacity requirements by POC due date 4/8/22. LPA contact information and capacity sheets were provided.
	8 9 10 11 12 13 14	This requirement was not met as the evidenced by: licensing staff observed 9 children in the facility (3 infants and 6 preschool children) with licensee and no assistant was present. This presents an immediate risk to the health and safety of children in care.	8 9 10 11 12 13 14	LPA will conduct follow up visit to verify compliance,
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin Tjhia	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 3 of 3