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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625439
Report Date: 01/09/2024
Date Signed: 01/09/2024 11:09:07 AM

Document Has Been Signed on 01/09/2024 11:09 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:KHIL,HUSSAIN KHATIRAFACILITY NUMBER:
343625439
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
01/09/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Khatira Hussain KhilTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Gagandeep Singh met with applicant, Khatira Hussain Khil, for a scheduled pre-licensing inspection at the facility. Applicant lives in a single story single family home. Applicant has provided the copy of the lease agreement. Because the applicant rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149). Child care will be provided in areas: Living Room, Hallway, Bathroom in the hallway, Bedroom on the left side at the end of the hallway, Kitchen, Dining area and Backyard. Off limit areas: Master bedroom, First bedroom on left side of the hallway, Garage and storage in the backyard. Applicant understands that all off limits areas must remain inaccessible to children. Applicant was notified that prior to use of any off limits area, the department must be notified. Child care will be provided between 8AM to 5 PM.

LPA Singh inspected the entire home with the applicant for health and safety hazards. The house has proper temperature and ventilation. All the toxic or dangerous materials are stored in off limit areas. Per applicant, there are not firearm or weapon in the house. There are no pets in the house. The house has a working telephone, smoke detector, fully charged fire extinguisher and carbon monoxide detector. There are no stairs in the house. Fireplace is barricaded with the furniture. There is a variety of age appropriate toys available. All unused electrical outlets have child protective covers installed. There is no pool, spa or other bodies of water on the property.

LPA reviewed with applicant the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children's forms/records, facility forms/records, and information to be posted. Applicant has submitted record of CPR training, but do not have the EMSA approval sticker to validate the training.
See next page for continuation ...........
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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: KHIL,HUSSAIN KHATIRA
FACILITY NUMBER: 343625439
VISIT DATE: 01/09/2024
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Applicant understands that fire/earthquake drills are to be conducted every 6 months and recorded. Applicant understands that baby walkers, bouncers, and excersaucers are not allowed. LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage at:
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep, as an additional resource. LPA also informed applicant 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 PIN 22-02-CCP. 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) or (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.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: KHIL,HUSSAIN KHATIRA
FACILITY NUMBER: 343625439
VISIT DATE: 01/09/2024
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On November 29, 2023, the California Attorney General - Megan's Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

During today's inspection, LPA did not observe any hazard in the house. Prior to issue the license, the applicant must submit record of completing EMSA approved CPR training to the Department.

Exit interview conducted and report was reviewed with the applicant, Khatira Hussain Khil. This report will be kept in the facility file and will be made available for public review upon request. Desk Duty is available Monday through Friday between 8 AM - 5 PM at (916) 263-5744.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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