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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343627400
Report Date: 11/19/2025
Date Signed: 11/19/2025 09:54:27 AM

Document Has Been Signed on 11/19/2025 09:54 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:KOHISTANI, ROYAFACILITY NUMBER:
343627400
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
11/19/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Kohistani, RoyaTIME VISIT/
INSPECTION COMPLETED:
10:30 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
This is a Change of Location from previous facility number 3436253.
On 11/19/2025 at 9:00 AM, Licensing Program Analysts (LPAs) Pa Dao Vang and Amanda Sutter met with Applicant, Roya Kohnistani, for a Change of Location Inspection. Applicant is requesting change of location for their Small Family Childcare Home License. The facility will operate Monday thru Friday for 24 hours. LPAs confirmed that all adults residing and working in the home have a criminal record clearance through Community Care Licensing. LPA observed two of Applicant’s own children present during the inspection. One of the children is under 10 years old and the other is over 10 years old. Applicants also speak in Dari. Applicant understands she must be present at the facility for 80% of operating hours.

The Applicant lives in one story home with 3 bedrooms, 3 bathrooms, laundry room, kitchen, living room, dining room, courtyard, front yard, shed, and backyard. Off Limit Areas include: bedroom #2, backyard, courtyard, shed, restroom #2, and laundry room. Applicant acknowledges that children may never enter these off-limit areas. LPAs observed a working 2A:10:BC fire extinguisher and a working smoke detector. Applicant will install a new carbon monoxide detector. Toys and the home appear to be safe and appropriate for children. Cleaning materials, hazardous items, and medications are all stored inaccessible to children. Applicant acknowledged there’s no smoking, weapons, nor poisons in the home. There are no bodies of water. Applicant understands 100% supervision shall be maintained in or around bodies of water, and in unfenced areas. Applicant has a valid CPR/First Aid certificate that will be expiring on 9/19/2027. The Applicant is also exempt from Mandated Reporter Training.

Continue on LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Seychelle De Luca
NAME OF LICENSING PROGRAM ANALYST: Dao Vang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2025
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 3
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)
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: KOHISTANI, ROYA
FACILITY NUMBER: 343627400
VISIT DATE: 11/19/2025
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
26
27
28
29
30
31
32
APPLICANT RENTS THE HOME: The applicant provided proof of control of property.

APPLICANT RENTS THE HOME AND NO LANDLORD CONSENT: The Applicant did not provide the Property Owner/Landlord Consent form (LIC 9149). Without this consent, the applicant understands that, once licensed, they can only operate with a maximum capacity of 6 children at a time. This capacity includes her own children under ages 10 years old.

LPA discussed the safe sleep regulations with the applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the 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. LPA discussed about the infant sleep log required for each child under the ages of 1 years old. Licensee must check and documenting each infant sleeping every 15 minutes.


LPA advised that the old facility number will be closed as of this date, and she is no longer able to operate in that location.

As of 11/19/2025, the facility is pending approval for a Small Family Child Care Home license, with a capacity of 6 children with no more than 3 infants or 4 infants only. Infants are children under ages 2 years old. Infants are children under the age of two years.

Pending Items below:

1. Install a working carbon monoxide

2. Cover the water fountain

3. Email images to LPA for approval

NAME OF LICENSING PROGRAM MANAGER: Seychelle De Luca
NAME OF LICENSING PROGRAM ANALYST: Dao Vang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3