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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625092
Report Date: 06/30/2023
Date Signed: 06/30/2023 03:02:23 PM

Document Has Been Signed on 06/30/2023 03:02 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:KHWAJA, FARZANA & ZIAULLAHFACILITY NUMBER:
343625092
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
06/30/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ziaullah and Farzana KhwajaTIME COMPLETED:
02:45 PM
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On June 30th, 2023 at 1:00pm, Licensing Program Analyst (LPA) Arianna Manabat met with applicants for the purpose of a scheduled pre-licensing inspection at the facility. Applicant has previous license (343623822) for child care home at a different location and applied for new license due to change of location. The applicant lives in a house with one child. The Licensees are aware that their own children are included in the ratio if they are present in the home.

All the adults living in the facility have a criminal background clearance on file. The hours of operation will be Monday to Sunday 24/7. The off-limit areas include the downstairs area, except for the front living room, garage, and the master bedroom. Applicant was notified that they would need to contact the department before making any on-limits areas to off-limits or vice versa.

LPA inspected the entire home with the applicant for health and safety hazards. All of the toxic or dangerous materials are inaccessible. The facility has a working telephone, fully charged fire extinguisher, first aid supplies, smoke detector, and carbon monoxide detector that meets regulations. As per the applicant, there are no firearms or weapons in the facility. Cabinets in the kitchen and drawers do not possess potential hazards inside.

Applicant was advised that all adults, 18 years and older living in the home, helper or assistant must have obtained a criminal record clearance and must be associated to the facility prior to working in the facility. This can be done by submitting an LIC 9182 with copy of CA DL or CA ID prior to having any contact with children in care. Failure to do so could result in an immediate civil penalty of $100.00 each day.
See next LIC 812-C for continuation ...........
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2023
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: KHWAJA, FARZANA & ZIAULLAH
FACILITY NUMBER: 343625092
VISIT DATE: 06/30/2023
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Continuation from LIC 812...........
LPA discussed the licensing regulations, safe sleep procedures, and provided applicant with information on how to access PINs online at the CCLD website. Applicant has submitted record of all the required immunization, and CPR. Applicant understands that fire/earthquake drills are to be conducted every 6 months and recorded. The applicant understands that baby walkers and smoking are prohibited within the facility.

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.

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



A copy of this report was reviewed and provided to applicant. This report will be kept in the facility file and will be made available for public review upon request. The Sacramento Regional Office is available Monday through Friday between 8 AM - 5 PM at (916) 263-5744.

Effective today, 06/30/2023, THE FACILITY IS LICENSED MAX. CAP: 6 - NO MORE THAN 3 INFANTS OR 4 INFANTS ONLY. CAP 8 - NO MORE THAN 2 INFANTS, 1 CHILD IN KINDERGARTEN OR ELEMENTARY SCHOOL AND 1 CHILD AT LEAST AGE 6.

OFF LIMITS: downstairs area, except for the front living room, garage, and the master bedroom.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC809 (FAS) - (06/04)
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