<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625092
Report Date: 11/16/2023
Date Signed: 11/16/2023 10:41:07 AM

Document Has Been Signed on 11/16/2023 10:41 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 - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Farzana & Ziaullah KhwajaTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 9am, Licensing Program Analyst (LPA), Michelle Perez, met with licensees Ziaullah and Farzana for the purpose of a capacity increase. Upon inspection, LPA observed five children in care (1 infant, 3 preschoolers and 1 school aged).

During the inspection, LPA observed an infant sleeping in a motorized baby swing. LPA explained that at no time can an infant be left to sleep in a swing, and that infants must be moved to an approved infant bed (crib, pack in play, mat, cot) to sleep.

Licensee immediately removed the child from the baby swing.

Today's visit resulted in one "A" citation on the 809-D.

Licensee is required to notify all current parents/guardians of the deficiency and to notify all incoming parents for one-year from the date of this licensing report. All parents/guardians must acknowledge this report by signing the LIC 9224, and the licensee will place the LIC 9224 in each children's file. Failure to sign and place in file will result in a separate citation.
A notice of site visit was provided. This report was reviewed with the licensees.

Appeal rights were provided.
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)
Page: 1 of 2
Document Has Been Signed on 11/16/2023 10:41 AM - It Cannot Be Edited


Created By: Michelle Perez On 11/16/2023 at 10:23 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KHWAJA, FARZANA & ZIAULLAH
FACILITY NUMBER: 343625092

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/17/2023
Section Cited
CCR
102425(I)

1
2
3
4
5
6
7
If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This was not evidenced by:
1
2
3
4
5
6
7
Licensee immediately removed the child from the swing and understands that infants must be placed in the appropriate beds. Licensee returned the swing to the guardian.
8
9
10
11
12
13
14
LPA observing an infant sleeping in a baby swing with the door closed.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Keven Peters
LICENSING EVALUATOR NAME:Michelle Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2