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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621889
Report Date: 05/11/2022
Date Signed: 05/11/2022 02:23:43 PM


Document Has Been Signed on 05/11/2022 02:23 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: 3DATE:
05/11/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Shazia KhanTIME COMPLETED:
02:40 PM
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On Wednesday, May 11, 2022, Licensing Program Analyst (LPA) Erwin Tjhia and Licensing Program Manager (LPM) Bettina Engelman met with licensee, Shazia Khan for Plan of Correction (POC) inspection.

On Thursday, May 5, 2022, facility was cited for ratio/capacity as the staff assistant was left alone with 11 children, including 4 infants. The facility was also cited that day for failure to provide Safe Sleep after LPA and LPM observed Infant #1 sleeping in a car seat, and Infant #2 sleeping in a high chair.



Upon arrival today, LPA and LPM observed 3 children, including 2 infants supervised by Licensee Shazia Khan and an assistant. LPA and LPM also observed one of the infants to be sleeping in a play yard. Moreover, LPA and LPM reviewed children's files and the files had complete records, including signed "Acknowledgement of receipt of Licensing Reports" (LIC 9224) from past deficiencies issued.

The deficiency cited on 04/26/2022 for Ratio and Capacity can be cleared today. The deficiency cited on 05/05/2022 for Safe Infant Sleep Practice can be cleared today.

In the areas that were evaluated today, no deficiencies were observed 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.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin TjhiaTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
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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