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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625419
Report Date: 12/12/2025
Date Signed: 12/12/2025 06:08:04 PM

Document Has Been Signed on 12/12/2025 06:08 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:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
12/12/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:ILhamudin KohistaniTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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On 12/12/2025 approximately at 3:30 PM, Licensing Program Analysts (LPAs) Pa Dao Vang and Payenda Seddiqi met with Licensee, ILhamudin Kohistani, for an unannounced Case Management inspection. The Licensee arrived at the facility at 3:35 PM. At 3:39 PM, LPAs observed one preschool-age child and six school-age children arrived at the door alone with no adult.

On 9/29/2025 at 3:10 PM to 3:12 PM, LPA Vang observed one preschool-age and five school-age children arrive. The children arrived alone and were not accompanied by an adult. LPA observed a child open the door for these newly arrived children. Based on observations and interviews, LPA determined children have access and enter off-limit areas of the home. LPA observed seven children in the home. As of today, the off-limits will garage, backyard, and bedroom #1.

On 9/29/2025 at 4:58 PM, LPA observed another one preschool-age and three school-age children arrive. The children also arrived alone and were not accompanied by an adult. The facility is licensed for a maximum of six children. When LPA discussed the limitations and capacity of the licensee, Licensee’s mother sent five children out. The children were not accompanied by an adult and went to the upstairs apartment.

Based on observations and review of documentation, LPA Vang determined Licensee falsified documents to receive subsidy program funds by showing inaccurate time in and out entries on monthly records when children were found not to be in attendance.


Continue on LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Seychelle De Luca
NAME OF LICENSING PROGRAM ANALYST: Dao Vang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2025
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.

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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: KOHISTANI, ILHAMUDIN
FACILITY NUMBER: 343625419
VISIT DATE: 12/12/2025
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Based on LPA’s observations, interviews, and file reviews, there are Title 22 deficiencies being cited in accordance with California Code of Regulations, (Title 22, Division 12 & Chapter 1), are being cited on the attached LIC809-D page.

The Licensee acknowledges, that for TYPE A DEFICIENCIES ONLY upon receipt, facility shall post LIC 809-D with Type A deficiency for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the Licensee.
NAME OF LICENSING PROGRAM MANAGER: Seychelle De Luca
NAME OF LICENSING PROGRAM ANALYST: Dao Vang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2025 06:08 PM - It Cannot Be Edited


Created By: Dao Vang On 12/12/2025 at 04:50 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: 12/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2025
Section Cited
CCR
102416.3(a)(6)

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Alterations to Existing Buildings or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following:
(6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidence by:
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LPA Vang updated the off-limit areas as of today. Licensee understood about off-limit areas and will make sure children do not access them.
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Based on LPA’s observation and children’s interview, the licensee did not comply with the section cited above when LPA witnessed the daycare children entering the off-limit areas of the facility. The children’s interview also stated that they’ve been accessing the off-limit areas. This poses an immediate health, safety or personal rights risk to persons in care.
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Type A
12/13/2025
Section Cited
CCR102416.5(a)

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Staffing Ratio and Capacity. The capacity specified on the license shall be the maximum number of children for whom care can be provided.

This requirement is not met as evidence by:
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Licensee submitted a LIC9149 form to LPA to update the capcity. Licsensee stated he understood the total of capacity.
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Based on observation, the licensee did not comply with the section cited above when LPA witnessed ten daycare children with two older siblings over 10 years old in the living room during facility hours. This poses an immediate health, safety or personal rights risk to persons 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: 12/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2025 06:08 PM - It Cannot Be Edited


Created By: Dao Vang On 12/12/2025 at 04:58 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: 12/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/12/2025
Section Cited
HSC
1596.885(c)

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Conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of this state.
This requirement is not met as evidenced by:
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Licensee will email LPA the plan of correction by 12/12/2025.
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Based on review of documentation and observations, LPA determined Licensee falsified documents to receive subsidy program funds by showing inaccurate time in and out entries on monthly records when children were found not to be in attendance. This poses an immediate health and safety risk.
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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: 12/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2025


LIC809 (FAS) - (06/04)
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