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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483008410
Report Date: 06/08/2023
Date Signed: 06/08/2023 10:04:57 AM


Document Has Been Signed on 06/08/2023 10:04 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:KHAKHA, SARPREET FCCHFACILITY NUMBER:
483008410
ADMINISTRATOR:KHAKHA, SARPREETFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 720-5491
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:14CENSUS: 10DATE:
06/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:14 AM
MET WITH:Facility RepresentativeTIME COMPLETED:
10:05 AM
NARRATIVE
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Licensing Program Annalyst ( LPA) arrived to the facility to make observations and interview staff and children. LPA arrived to the facility at 08:14AM there were seven children in care with the Facility representative. While LPA was in the home, two additional children arrived to the facility making the total nine children with the facility representative alone until the assistant arrived at 08:35AM.

Regulation 102416.5(e) is being cited on the attached 809-D page.
Exit interview was conducted and report was reviewed. Notice of site visit must be posted for 30 days.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
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 06/08/2023 10:04 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: KHAKHA, SARPREET FCCH
FACILITY NUMBER: 483008410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/22/2023
Section Cited
CCR
102416.5(e)

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102416.5 Staffing Ratio and Capacity
(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). This was not met as evideence by. . .
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Facility representative stated in the furture she will have her another staff member present if assistant calls to say they will be late. Facilty representative reported she will require assistant to notify of absence or lateness a day before to ensure back up assistant is present.
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Based on LPA Observation the facility repesentative was alone in the facility from 08:14AM- 08:35AM with 10 children. This poses a potential health and 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: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
LIC809 (FAS) - (06/04)
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