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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343617830
Report Date: 01/05/2024
Date Signed: 01/05/2024 03:22:33 PM

Document Has Been Signed on 01/05/2024 03:22 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KHAN, SAMINAFACILITY NUMBER:
343617830
ADMINISTRATOR:KHAN, SAMINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 688-3642
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
01/05/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Samina KhanTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Gagandeep Singh met with licensee, Samina Khan, and two helpers for an annual inspection. The purpose of the inspection was explained. Licensee lives in a single story home. During inspection, there are six children in care with licensee and two helpers. All adults living or working in the home have criminal background check on file. Licensee is operating within the capacity of this date. Licensee provides day care from Monday to Friday between 6:30 AM to 6 PM.

LPA inspected the day care areas with the licensee. Day Care Areas: Family room, small room on right side of main entrance, Hallway, Bathroom in hallway, Kitchen, Dining area, Living room, Sunroom and Backyard. Off limit areas: All bedrooms, Laundry room and Garage. There is no pool, spa or any other body of water in the house. As per licensee, there is no firearm or weapon in the house. The house is in good repair and free of hazards with proper temperature and ventilation. LPA observed there is carbon monoxide detector, smoke detector, fully charged fire extinguisher and working telephone available in the house. Fireplace is barricaded with metal screen. All the cleaning supplies, poisons and other chemicals are stored inaccessible to the children. Knives are stored in the high cabinet in the kitchen. There is a variety of age appropriate toys in the house.

LPA reviewed the facility records. LPA observed licensee has License and other required documents posted in the child care areas. Licensee has record of training of preventive health and CPR card valid until June 2025. Licensee is aware that the fire or emergency drills must be conducted at least once every six months and drills must be logged. Licensee has a log in place and per log, last drill was conducted on November 10, 2023. LPA also reviewed the present children's record. LPA reviewed the identification and emergency information form for every child for proper names and numbers filled. Licensee has record of immunization of each child in care. Licensee has well maintained children roster on file. Licensee has mandated reporter training completion certificate valid until June 08, 2024. See next page for continuation ...
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KHAN, SAMINA
FACILITY NUMBER: 343617830
VISIT DATE: 01/05/2024
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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.

LPA discussed with Licensee the safe sleep regulations and 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 L1 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.

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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

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.

Exit interview conducted and report was reviewed with the licensee. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC809 (FAS) - (06/04)
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