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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004550
Report Date: 03/08/2022
Date Signed: 03/08/2022 03:06:18 PM

Document Has Been Signed on 03/08/2022 03:06 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SHAKIL'S CARE HOMEFACILITY NUMBER:
347004550
ADMINISTRATOR:KHAN, SHAKILFACILITY TYPE:
735
ADDRESS:12717 HAUSCHILDT ROADTELEPHONE:
(209) 200-3046
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 4CENSUS: 4DATE:
03/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sarfaz Khan, House ManagerTIME COMPLETED:
03:20 PM
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
On 03/08/2022 at 2:00pm, Licensing Program Analysts (LPAs) T. White and R. Campbell arrived unannounced to conduct a case management visit. LPAs met with House Manager, Natalie Willman and Sarfaz Khan. LPAs explained the purpose of the visit.

On 03/02/2022, LPA Bilger spoke with Administrator to confirm update on COVID cases. Based on interview, the facility completed first round of testing on 01/31/2022. The facility informed LPA Bilger a second round of testing needed to be completed.

On 03/08/2022, LPA White reviewed COVID response testing results. Based on documentation, staff and clients did not complete 2nd round of COVID testing.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with House Manager. A copy of report and Appeal Rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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 2
Document Has Been Signed on 03/08/2022 03:06 PM - It Cannot Be Edited


Created By: Treana White On 03/08/2022 at 02:50 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SHAKIL'S CARE HOME
FACILITY NUMBER: 347004550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2022
Section Cited
CCR
1550(c)

1
2
3
4
5
6
7
1550(c): Licenses or administrator certificate:(c)Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home.

This requirement was not met as evidence by:
1
2
3
4
5
6
7
House Manager agreed to conduct in-service training with all staff and submit proof to CCLD by POC date. House Manager agreed to conduct testing for all staff by 03/15/2022 and submit proof to LPA.
8
9
10
11
12
13
14
Based on observation and interview, facility did not comply with the section 1550(c). LPA observed facility did not conduct 2 rounds of testing, which is a potential health and safety risk to clients.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2