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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621889
Report Date: 03/08/2021
Date Signed: 03/08/2021 04:33:02 PM

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 250
SACRAMENTO, CA 95833
FACILITY NAME:KHAN, SHAZIAFACILITY NUMBER:
393621889
ADMINISTRATOR:KHAN, SHAZIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 263-9371
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:14CENSUS: 4DATE:
03/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Licensee, Shazia KhanTIME COMPLETED:
03:00 PM
NARRATIVE
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The facility was contacted via FaceTime video call due to the recent COVID19 State of Emergency. Licensing Program Analyst (LPA) Chayntel Hunter spoke with Licensee, Shazia Khan for the purpose of a case management visit.. In lieu of Licensee's signature, LPA Hunter is emailing the report with a read receipt request.

During a recent investigation, it was revealed that staff member (S1) was left alone to supervise children in care without a CPR certification. While conducting a record review for S1 it was also determined that the individual was missing documents to be maintained in a staff file.

During the investigation, LPA also learned that a child was injured on 02/17/21 at the facility. LPA learned that the Licensee did not report the incident to Licensing. Licensee admitted that she forgot to report the incident to Licensing.

A Title 22 DEFICIENCY was cited on the subsequent page LIC 809-D of this report. Appeals rights were discussed and printed. An exit interview was conducted. A Notice of Site Visit was provided for Licensee to post
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: KHAN, SHAZIA
FACILITY NUMBER: 393621889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2021
Section Cited

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HSC 1596.886 (b)... Licensees of family day care homes shall ensure that at least one staff member who has a current course completion card in pediatric first aid and pediatric CPR... shall be onsite at all times when children are present at the facility... This requirement was not met as evidenced by:
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Based on interviews conducted it was revealed that S1 was left alone to supervise children in care without a CPR certification. This is a potential health and safety risk to children in care.
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Type B
04/08/2021
Section Cited

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Personnel Records 102416 (a) Personnel records shall be maintained on each employee and shall contain the following information: (11) A signed statement regarding their criminal record history as required by Section 102370(c). This requirement was not met as evidenced by:
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Based on records reviewed it was determined that S1 did not have a complete staff personnel file and was missing documents including the criminal record statement. This is a potential health and safety risk to children 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.
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: KHAN, SHAZIA
FACILITY NUMBER: 393621889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2021
Section Cited

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Reporting Requirements 102416.2(b) The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home. This requirement was not met as evidenced by:
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Based on interviews conducted it was revealed that a child was injured in care and that the Licensee did not report the incident to Licensing and a written report was not submitted, This is a potential health and safety risk to children 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.
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3