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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625092
Report Date: 11/16/2023
Date Signed: 11/16/2023 10:40:00 AM

Document Has Been Signed on 11/16/2023 10:40 AM - 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: 5DATE:
11/16/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Farzana & Ziaullah KhwajaTIME COMPLETED:
11:00 AM
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At approximately 9AM, Licensing Program Analyst (LPA), Michelle Perez, met with licensees Farzana and Ziaullah for the purpose of a capacity increase. During today's visit there were five children present to include, 3 preschoolers, 1 infant and 1 school aged. LPA verified all changes were made that the were requested of the licensees, from the fire department.

The two-story home, has been approved by the fire department to be eligible for a large family day care upstairs, due to the entire house having a full sprinkler system inside. The stairs are gated. The licensees have requested to change their on and off limit areas. Licensee is requesting to add the master bedroom and bathroom on limits, and has moved all toxic and hazardous chemicals out of reach of children. The loft area is on limits and the garage is now added to be on limits, to use when children will be getting additional toys out of it. LPA verified there are no hazards present within the garage.

OFF LIMIT AREAS: Kitchen area only. Children will use the side patio door to enter the garage and will not use the kitchen to access the garage. CPR expires: March 2024.

Cont on 809-C






SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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: 11/16/2023
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Effective today, November 16, 2023, this home is licensed for a large family child care facility.

The facility is approved for a large capacity to serve 12 children (when there is an assistant present) with no more than 4 infants or capacity of 14 children when 1 child in kindergarten or elementary school and 1 child at least age 6 and a maximum of 3 infants. Infants are children under the age of two years.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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