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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625419
Report Date: 09/29/2025
Date Signed: 12/12/2025 05:15:50 PM

Document Has Been Signed on 12/12/2025 05:15 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:KOHISTANI, ILHAMUDINFACILITY NUMBER:
343625419
ADMINISTRATOR/
DIRECTOR:		KOHISTANI, LLHAMDUINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 710-4762
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
09/29/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:48 PM
MET WITH:Kohistani, ILhamudinTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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This is an amended report on 12/12/2025.

On 9/29/2025 approximately at 2:30 PM, Licensing Program Analysts (LPAs) Pa Dao Vang met with Licensee, ILhamudin Kohistani, for a Case Management inspection. LPA observed seven children under ages 10 years old in daycare.

There are four other non-employee adults present in the home during the inspection. Three of the adults obtained background clearances. One of them have no background clearance associated to the facility. Licensee stated that he's a family member and is currently visiting.

Licensee requested to updated the off-limits in the home. The home consist of bedroom #1, bedroom #2 with a restroom , #3, bathroom, kitchen/living room/ dinning room, garage, backyard, and front yard. The off-limits: backyard, garage, and front yard.

During today's inspection, LPA reviewed four children’s files with only LIC995A and LIC9150. LPA observed and reviewed three children's files with only the LIC9150 form. Licensee stated that he was working on the other forms at their family market, where his brother and sister have a printer. LPA Vang provided a packet of required documents for each child’s file.

Based on LPA observations, file reviews and interview conducted, a deficiency is being cited on page LIC809-D page in accordance with the California Code of Regulations, Title 22. This report and appeal rights were reviewed and provided to Licensee ILhamudin Kohistani. A notice of site visit was also provided to be posted for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Seychelle De Luca
NAME OF LICENSING PROGRAM ANALYST: Dao Vang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/29/2025 05:19 PM - It Cannot Be Edited


Created By: Dao Vang On 09/29/2025 at 04:30 PM
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: KOHISTANI, ILHAMUDIN
FACILITY NUMBER: 343625419

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2025
Section Cited
CCR
102421(a)

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The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement was not met as evidenced by:
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Licensee will obtain complete the files and LPA Vang will retun to to review them.
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LPA conducted file review of children's files and observed 7 out of 7 children missing a forms with incomplete files.
This is a potential risk to the health and safety of 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.
Seychelle De Luca
NAME OF LICENSING PROGRAM MANAGER:
Dao Vang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2025


LIC809 (FAS) - (06/04)
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