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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503904174
Report Date: 10/10/2022
Date Signed: 10/10/2022 12:48:05 PM

Document Has Been Signed on 10/10/2022 12:48 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:KHOSHABA, NAHRAIN FAMILY CHILD CAREFACILITY NUMBER:
503904174
ADMINISTRATOR:KHOSHABA, NAHRAINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 622-0244
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
10/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nahrain KhoshabaTIME COMPLETED:
01:00 PM
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On 10/10/2022, Licensing Program Analysts (LPAs) Ka Vang and Cynthia Brannon conducted an unannounced case management inspection. LPAs were greeted by Licensee Nahrain Khoshaba. Present during today's inspection was Licensee’s Assistant Staff #2 (S2). Census was taken and there were eight children in the facility. The purpose of today's inspection was to conduct an unannounced case management inspection regarding license facility number not on advertisement and safe sleep.

At 10:30 AM, LPAs arrived at the facility. LPAs observed the front yard had a sign outside advertising the day care service. LPAs observed the sign and the sign had Licensee’s name and phone number with the age group children licensee served. The advertisement sign did not have Licensee’s facility number. LPAs advised Licensee that Licensees shall reveal her facility license number in all advertisements, publications, or announcements that she made intend to attract clients.



As LPAs conducted a tour of the inside facility, LPAs observed one of the approved bedroom door was closed. Licensee open the door as there was a child cry sound came out from the room. LPA asked Licensee as to why the bedroom door was closed and Licensee stated that she closed the door due to a day care child was asleep in the play yard inside the room. Licensee opened the bedroom door and observed that Child #1 (C1) was in the play yard awake and standing up inside the play yard. LPAs advised Licensee that if the infant is sleeping in a separate room from where the licensee is stationed, the door to the room the infant is sleeping in shall remain open at all times. The provider shall be able to visually observe the infant without moving the door.

Furthermore, as LPAs continued the inspection tour, LPAs also observed infant Child #2 (C2) was on the baby play mate on the floor with a small blanket and a large blanket. The C2 was on the baby play mate next to C2. LPAs advised Licensee that cribs or play yards shall be free from all loose articles and objects. C2 immediately removed the blankets.

(Continued on LIC 809-C).

SUPERVISORS NAME: Michael Duarte
LICENSING EVALUATOR NAME: Ka Vang
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: KHOSHABA, NAHRAIN FAMILY CHILD CARE
FACILITY NUMBER: 503904174
VISIT DATE: 10/10/2022
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Per California Code of Regulations, Title 22, Division 12, Chapter 3, no deficiency cited.

An exit interview was conducted with licensee Nahrain Khoshaba.

A copy of this report and appeal rights were provided. A note of Site Vist form was posted to the Parent’s Board and it must remain posted for 30 days.

SUPERVISORS NAME: Michael Duarte
LICENSING EVALUATOR NAME: Ka Vang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022
LIC809 (FAS) - (06/04)
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