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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500768
Report Date: 07/24/2025
Date Signed: 07/24/2025 11:39:35 AM

Document Has Been Signed on 07/24/2025 11:39 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SAFI, NAZIFAFACILITY NUMBER:
344500768
ADMINISTRATOR/
DIRECTOR:		SAFI, NAZIFAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 548-6538
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 0DATE:
07/24/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Vela SafiTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On July 24, 2025 Licensing Program Analyst (LPA) Jennie Tedlos arrived at the facility for the purpose conducting a Plan of Correction Inspection. LPA met with Licensee's Assistant, Vela Safi. LPA used the department's translation services during today's visit. LPA did not observe any children during the inspection.

The facility was inspected on June 9, 2025 at which time a deficiency was cited related regarding Children's Records. The facility did not have the required licensing records for the children in care. A plan of correction was developed during the inspection. During today's visit, LPA observed and reviewed the records of the children enrolled at the facility.

The deficiency cited on June 9, 2025 are cleared effective today. Proof of correction letter was provided for the corrected deficiency.

During today's inspection, it was revealed that the Licensee, Nazifa Safi, has been absent from the facility for an extended period of time. The Assistant Vela Safi was watching the children enrolled during this period of time. Licensees may not be absent from the facility for more than 20 percent of the facility's operating hours every day.

A Type-A Deficiency is assessed on the subsequent 809-D page regarding Operation of a Family Child Care Home. LPA will conduct an unannounced POC visit to clear the deficiency.

Exit interview conducted and report was reviewed with Assistant Vela Safi. A notice of site visit was given and must remain posted for 30 days. Appeal Rights were provided. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
NAME OF LICENSING PROGRAM MANAGER: Karyn Guerra
NAME OF LICENSING PROGRAM ANALYST: Jennie Tedlos
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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 07/24/2025 11:39 AM - It Cannot Be Edited


Created By: Jennie Tedlos On 07/24/2025 at 11:15 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: SAFI, NAZIFA
FACILITY NUMBER: 344500768

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2025
Section Cited
CCR
102417(a)

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102417 Operation of a Family Child Care Home (a).... When... the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care... during his/her absence. Temporary absences shall not exceed 20 percent of the...
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LPA clarified the regulations for Licensee's temporary absences at the facility. The facility will not provide day care for children while the Licensee is absent from the facility. LPA will conduct an unannounced POC visit to clear the deficiency.
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... hours that the facility is providing care per day.
This regulation was not met as evidenced by:
Licensee is on vacation away from the facility while the facility is still in operation.
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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.
Karyn Guerra
NAME OF LICENSING PROGRAM MANAGER:
Jennie Tedlos
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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