<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503904174
Report Date: 06/29/2023
Date Signed: 06/29/2023 02:09:44 PM

Document Has Been Signed on 06/29/2023 02:09 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
FRESNO-CC, 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: 7DATE:
06/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Nahrain KhoshabaTIME COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/29/2023 Licensing Program Analysts (LPA) Julie Baptista and Kari McWilliams, conducted an unannounced Annual Required Inspection and was met by Licensee, Nahrain Khoshaba. Also present was Staff #1 (S1) and adult daughter. Days and hours of operation are Monday through Friday 5:00 AM to 5:30 PM. The home has working telephone service and LPA confirmed the phone number on file.
LPA toured the home inside and outside and a census was taken. Licensee confirmed that the family room, day care room, optional bonus room, bathroom and living room are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of gates. The outdoor play area in the backyard is fenced. The climbing structure in the back yard has chipped paint and the wood underneath is rough. The structure also has a slide that is broken and the slide has been removed from the structure but was in the flower bed accessible to children. LPA discussed with licensee that the slide will be put away where it is inaccessible to children. LPA also discussed with licensee that the climbing structure needs to be repaired/painted. Licensee stated she had been interviewing handymen to have them fix but says she may just replace it. LPAs observed a bottle of pesticide in the flower bed of the back yard. Children were not outside at the time of inspection and children had not been outside per the licensee. Licensee removed the pesticide and put it in a locked storage shed. See 809-D. There is one cat and two small dogs. Licensee understands the liability of pets around day care children and accepts responsibilities of any action taken by pets. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.
The fireplace located in the family room is made inaccessible by a glass door and will not be in use during daycare hours. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. This is a two story home. There is a gate secured on the first step of the staircase. Safe toys and play equipment are observed.
Licensee was not aware of the new safe sleep regulations. LPAs observed sleeping infant in the family room during inspection. LPAs observed Licensee checking on infant and staying in the family room with the sleeping infant. However Licensee does not document 15 minute sleep check. LPA gave licensee an example of 15 minute check log.
Continued on 809-C
SUPERVISORS NAME: Cynthia Brannon
LICENSING EVALUATOR NAME: Julie Baptista
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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 10
Document Has Been Signed on 06/29/2023 02:09 PM - It Cannot Be Edited


Created By: Julie Baptista On 06/29/2023 at 12:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: KHOSHABA, NAHRAIN FAMILY CHILD CARE
FACILITY NUMBER: 503904174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in the climbing structure in the back yard has chipped paint and the wood underneath is rough. The structure also has a slide that is broken and the slide has been removed from the structure but was in the flower bed asscessable to children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2023
Plan of Correction
1
2
3
4
Licensee stated she will make the climbing structure inaccessable to children. Licensee agrees to either repair/replace structure or remove it from play yard.
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview the licensee did not comply with the section cited above in that LPAs observed a bottle of pestacide in the flower bed of the back yard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2023
Plan of Correction
1
2
3
4
Children were not outside at the time of inspection. Licensee removed the pestacide and put it in a locked storage shed during inspection.
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:Cynthia Brannon
LICENSING EVALUATOR NAME:Julie Baptista
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 06/29/2023 02:09 PM - It Cannot Be Edited


Created By: Julie Baptista On 06/29/2023 at 12:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: KHOSHABA, NAHRAIN FAMILY CHILD CARE
FACILITY NUMBER: 503904174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in that Assistant has completed the Mandated Reporter Training on 2/04/19 but has not renewed the training every two years as required. Licensee does not remember taking the MRT training. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2023
Plan of Correction
1
2
3
4
 LPA reviewed the requirement with licensee. Licensee stated she will take the training and obtain completion certificate from assistant by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Cynthia Brannon
LICENSING EVALUATOR NAME:Julie Baptista
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 06/29/2023 02:09 PM - It Cannot Be Edited


Created By: Julie Baptista On 06/29/2023 at 12:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: KHOSHABA, NAHRAIN FAMILY CHILD CARE
FACILITY NUMBER: 503904174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in five out of six children's files, the LIC 995A Family Child Care Home Notification of Parents's Rights was not in the file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2023
Plan of Correction
1
2
3
4
LPA provided a copy of LIC 995A to licensee and reviewed requirement. Licensee agrees to complete the form with parents and copy to children's files.

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:Cynthia Brannon
LICENSING EVALUATOR NAME:Julie Baptista
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023


LIC809 (FAS) - (06/04)
Page: 4 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: KHOSHABA, NAHRAIN FAMILY CHILD CARE
FACILITY NUMBER: 503904174
VISIT DATE: 06/29/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. Capacity as specified on the license is being maintained.
LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. In five out of six children's files, the LIC 995A Family Child Care Home Notification of Parents’ Rights was not in the file. LPA reviewed requirement with licensee. See 809-D. Licensee’s Mandated Reporter Training was not completed. The assistant has completed the Mandated Reporter Training on 2/04/19 but has not renewed the training every two years as required. LPA reviewed the requirement with licensee and licensee stated she will take the training. Licensee’s pediatric CPR/First Aid expires on 3/04/2025. LPA reminded licensee that a copy of all required immunizations should be kept on file at facility.
All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) are not currently being provided. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm)
SUPERVISORS NAME: Cynthia Brannon
LICENSING EVALUATOR NAME: Julie Baptista
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC809 (FAS) - (06/04)
Page: 9 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: KHOSHABA, NAHRAIN FAMILY CHILD CARE
FACILITY NUMBER: 503904174
VISIT DATE: 06/29/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.
To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D)

Exit interview conducted and report with appeal rights was reviewed with the licensee, Nahrain Khoshaba.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Cynthia Brannon
LICENSING EVALUATOR NAME: Julie Baptista
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC809 (FAS) - (06/04)
Page: 10 of 10