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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343617830
Report Date: 05/14/2026
Date Signed: 06/26/2026 08:14:08 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/08/2026 and conducted by Evaluator Gagandeep Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20260108144225
FACILITY NAME:KHAN, SAMINAFACILITY NUMBER:
343617830
ADMINISTRATOR:KHAN, SAMINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 688-3642
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:14CENSUS: 8DATE:
05/14/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Samina KhanTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Uncleared adult(s) reside in the home.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gagandeep Singh met with the licensee, Samina Khan, to deliver the findings for the above allegations. Purpose of the inspection was explained.

During the investigation, interviews of random parents, children, licensee and adult living in home were conducted. Based on the information collected, it was found that licensee’s adult son moved into the house in October 2025 resided at the same address. Based on record review, it was found that the adult followed the live scan process in November 2025, but the clearance or exemption has not been granted. Based on LPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Copy of this report was reviewed and provided to the licensee. See next page for citation issued and civil penalties assessed today. Notice of site visit is posted and shall remain posted for next 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeevun Birk-Miller
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 03-CC-20260108144225
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2026
Section Cited
CCR
102370(d)(1)
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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.
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Licensee agreed that the uncleared adult will not reside at this facility. Per Licensee, the uncleared adult has been residing at realitive's house. Licensee agreed to provide the proof of current residence of the adult to the department.
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This requirement is not met as evidenced by record review and interviews, it was found that licensee’s adult son reside at this child care home and does not have criminal background clearance or exemption approved. This poses an immediate health and safety 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.
SUPERVISORS NAME: Jeevun Birk-Miller
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/08/2026 and conducted by Evaluator Gagandeep Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20260108144225

FACILITY NAME:KHAN, SAMINAFACILITY NUMBER:
343617830
ADMINISTRATOR:KHAN, SAMINAFACILITY TYPE:
810
ADDRESS:7173 CLEARBROOK WAYTELEPHONE:
(916) 688-3642
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:14CENSUS: 8DATE:
05/14/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Samina KhanTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Adult in the homes conduct poses a risk to children in care.
Adult resident hit child.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gagandeep Singh met with the licensee, Samina Khan, to deliver the findings for the above allegations. Purpose of the inspection was explained.

During the investigation, facility records were reviewed and interviews of random parents, children, licensee and adult living in home were conducted. During the interviews, no evidence to support the allegations was obtained. Based on the information collected, it was found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Copy of this report was reviewed and provided to the licensee. Notice of site visit is posted and shall remain posted for next 30 days.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeevun Birk-Miller
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3