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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422337
Report Date: 06/17/2026
Date Signed: 06/17/2026 05:56:30 PM

Document Has Been Signed on 06/17/2026 05:56 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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:SHAH, HINAFACILITY NUMBER:
013422337
ADMINISTRATOR/
DIRECTOR:		SHAH, HINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 377-2622
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
06/17/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:59 PM
MET WITH:Hina ShahTIME VISIT/
INSPECTION COMPLETED:
06:10 PM
NARRATIVE
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On June 17, 2026, at 1:59PM, Licensing Program Analyst (LPA) Randy Miranda met with licensee Hina Shah for the purpose of conducting an unannounced annual inspection for compliance to health and safety. Living in the home is the licensee and her TB tested and fingerprint cleared spouse. Present for the inspection were the licensee, licensee’s spouse, licensee’s assistant, and seven (7) children in care (3 infants, 2 two-year-old, and 2 three-year-old.). The hours of operation are Monday-Friday, 8:00am to 5:00pm. Licensure - Max. Cap (When there is an Assistant Present): 12 – No more than 4 infants. Cap 14 – No more than 3 infants. 1 Child in Kindergarten or Elementary School and 1 Child at least age 6. Total capacity is 14.

The facility is a two-story home with 3 bedrooms, 2 bathrooms, a living room, family room, kitchen, dining room, attached 2-car garage, backyard, and side yards.

ON-LIMIT AREAS: Family Room (day care area), kitchen, downstairs ½ bathroom, and backyard.
OFF-LIMIT AREAS: Entire upstairs area, downstairs bedroom, living room, and attached 2-car garage.
ISOLATION AREA: Family Room area. When a child shows signs of illness, he or she will be separated from other children in care.

There were ample age-appropriate toys observed, all safe and in good condition. The day care area and bathroom were neat and clean, with adequate heating and ventilation to ensure safety and comfort. A fully charged 2A10BC fire extinguisher is in the kitchen area. The smoke and carbon monoxide detectors were tested and found to be operational. A working telephone and a fully stocked first aid kit were also available.
NAME OF LICENSING PROGRAM MANAGER: Wynn Norona
NAME OF LICENSING PROGRAM ANALYST: Randy Miranda
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/17/2026 05:56 PM - It Cannot Be Edited


Created By: Randy Miranda On 06/17/2026 at 03:58 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: SHAH, HINA
FACILITY NUMBER: 013422337

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(a)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above in which a crib was not provided for the 7 month old infant. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2026
Plan of Correction
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Licensee shall provide a crib for the 7 month old infant during nap time. Licensee will ensure safe sleep regulations are followed. Licensee to provide photo proof or visit by LPA to clear POC.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not completing LIC 9227 and placing it in the infant's file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2026
Plan of Correction
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LIC 9227 shall be completed and signed by parents or authorized representative. Due date for completed LIC 9227 form is June 26, 2026. Photo proof or visit by LPA to clear POC.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wynn Norona
NAME OF LICENSING PROGRAM MANAGER:
Randy Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2026


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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SHAH, HINA
FACILITY NUMBER: 013422337
VISIT DATE: 06/17/2026
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The Fire Marshal granted fire clearance on May 18, 2022, and designated the second story and garage as off-limits to children in care. The licensee owns the home and carries liability insurance through Markel. According to the licensee, there are no firearms in the home. Disaster drills were last conducted on June 10, 2026. All required licensing documents were posted and visible for public review.

The licensee and all adults living in the home are following immunization laws pertaining to day care providers. Children’s files were reviewed and found to be complete and in good order. The licensee’s assistant is fingerprint cleared; however, the licensee did not associate the assistant with the facility. The facility roster was also reviewed, and a copy was obtained.

The licensee’s Pediatric CPR/First Aid certification is current and expires on September 27, 2027. Mandated Reporter Training was completed and expires on June 26, 2026. The assistant does not have a First Aid/CPR certification; however, their Mandated Reporter certificate expires on February 9, 2028. LPA reminded the licensee that both Mandated Reporter Training and CPR/First Aid must be renewed every two years. LPA also reminded the licensee that baby bouncers and drop-down cribs are not permitted in family child care homes.

Effective August 1, 2003, California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail. The licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

NAME OF LICENSING PROGRAM MANAGER: Wynn Norona
NAME OF LICENSING PROGRAM ANALYST: Randy Miranda
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SHAH, HINA
FACILITY NUMBER: 013422337
VISIT DATE: 06/17/2026
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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) or (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.

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-andresources/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 was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 email inquiries 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/inspection-process.

Two deficiencies were issued during today's inspection. Please see LIC 809-D. This report will remain on file for three years. A notice of site visit was given and must remain posted for 30 days. Appeal Rights provided.



Exit interview conducted and report was reviewed with the licensee, Hina Shah.
NAME OF LICENSING PROGRAM MANAGER: Wynn Norona
NAME OF LICENSING PROGRAM ANALYST: Randy Miranda
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
LIC809 (FAS) - (06/04)
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