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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483003617
Report Date: 06/13/2023
Date Signed: 06/13/2023 10:50:14 AM


Document Has Been Signed on 06/13/2023 10:50 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:WAHID, SHONNA FAMILY CHILD CARE HOMEFACILITY NUMBER:
483003617
ADMINISTRATOR:WAHID, SHONNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 435-0525
CITY:SUISUNSTATE: CAZIP CODE:
94585
CAPACITY:14CENSUS: 6DATE:
06/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Licensee Shonna WahidTIME COMPLETED:
11:00 AM
NARRATIVE
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During the course of a complaint investigation, it was determined that the Licensee did not report an incident alleging child abuse when made aware of the allegation during the time period in question in 2015 or more recently on 03/14/2023 when alerted of the prior alleged abuse. A Licensee is considered a mandated reporter and shall report to the Department any knowledge of suspected child abuse or neglect, regardless of whether or not suspected abuse is known or proven to have occurred, and/or any unusual incident that threatens the physical or emotional health or safety of any child.

Licensee is being cited in accordance with 102416.2(b)(3)(C) of the California Code of Regulations on the attached LIC809D report for failing to report the incident to the Department. Appeal Rights were provided. Exit interview conducted and report was reviewed with Licensee, Shonna Wahid. A notice of site visit was given 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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023
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 06/13/2023 10:50 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: WAHID, SHONNA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483003617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2023
Section Cited
CCR
102416.2(b)(3)(C)

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The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections. . . Any unusual incident or child absence that threatens the physical or emotional health or safety of any child. This was not met as evidence by. . .
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LPA printed and reviewed Reporting requirments with Licensee and reviewed Unusual incident procedure with Licensee. Licensee agreed to submit self certification LIC 9098 with plan of correction outlining the steps of submitting a UIR.
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Based on interviews licensee failed to report incident to the depermant. This causes a potential health or safty risk to 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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023
LIC809 (FAS) - (06/04)
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