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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621889
Report Date: 04/26/2022
Date Signed: 04/26/2022 02:58:31 PM


Document Has Been Signed on 04/26/2022 02:58 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: 11DATE:
04/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Shazia KhanTIME COMPLETED:
03:30 PM
NARRATIVE
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On 04/26/2022, 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 04/07/2022. As licensing staff arrived, they observed licensee in a vehicle in the driveway, ready to leave for pick-ups. Licensee explained that an adult assistant was inside, caring for daycare children. Inside the facility, there was an adult assistant with 11 children, including 5 infants. Licensee did not leave the premises, and made arrangements for somebody else to do the pick-up at school.

LPA toured the home and reviewed records. On 04/07/2022, facility was cited a Type A deficiency for ratio/capacity. Today, LPA observed 11 children, including 5 infants.

The deficiency cited on 4/7/2022 cannot be cleared today. A Type A deficiency was cited on the subsequent page 809-D of this report. This is a repeat violation and civil penalties in the amount of $250 were assessed today.

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: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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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Document Has Been Signed on 04/26/2022 02:58 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: 04/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2022
Section Cited

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Staffing Ratio and Capacity: 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).
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This requirement was not met as evidenced by: Licemsee's assistant was left alone with 11 daycare children, including 5 infants.
This is a repeat violation and civil penalites were assessed today.
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Licensee stated that she will submit a written statement on how she will maintain capacity limits, including number of infants and limits when there is only one staff member present and capacity reverts to Small Family Child Care Home ratios. LPA will conduct repeat visit to verify compliance.

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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: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
LIC809 (FAS) - (06/04)
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