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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621889
Report Date: 05/05/2022
Date Signed: 05/05/2022 03:14:28 PM


Document Has Been Signed on 05/05/2022 03:14 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:
05/05/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Shazia KhanTIME COMPLETED:
03:30 PM
NARRATIVE
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On 05/05/2022, 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 04/26/2022. As licensing staff arrived, licensee was not at facility. LPA called the licensee and licensee said that she would ask her staff assistant to open the door. Inside the facility, the staff assistant was by her self with 11 children, including 4 infants. Licensee returned back to the facility 10 minutes later.


LPA toured the home and reviewed records. On 04/25/2022, facility was cited a Type A deficiency for ratio/capacity. Today, LPA observed 11 children, including.4 infants.

The deficiency cited on 4/26/2022 cannot be cleared today. Civil penalties were assessed for failure to correct his deficiency.

LPA and LPM observed Infant #1 sleeping in a car seat, and Infant #2 sleeping in a high chair. A Type A deficiency was cited for these infants not sleeping in a crib or play yard.

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: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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 05/05/2022 03:14 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: 05/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2022
Section Cited

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INFANT SAFE SLEEP - (h) Car seats shall only be used for transportation purposes and shall not be used for sleeping.
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This requirement was not met as evidences by "LPA and LPM observed Infant #1 sleeping in a car seat, and Infant #2 sleeping in a high chair". This is an immidiate 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: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2