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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 393621889
Report Date: 11/21/2024
Date Signed: 11/21/2024 10:43:59 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/16/2024 and conducted by Evaluator Erwin Tjhia
COMPLAINT CONTROL NUMBER: 53-CC-20241016092829
FACILITY NAME:KHAN, SHAZIAFACILITY NUMBER:
393621889
ADMINISTRATOR:KHAN, SHAZIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 263-9371
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:14CENSUS: 8DATE:
11/21/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Shazia KhanTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Licensee did not provide infant their formula
Daycare child sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erwin Tjhia met with Licensee, Shazia Khan to deliver findings of the complaint investigation regarding the above allegations. There were 8 children and 2 staff during the visit.

It was alleged that Licensee did not provide infant their formula. Throughout the investigation, LPA conducted record review and interviews with licensee, staff, and parents. Interview with licensee and staff revealed that the child was offered bottle prepared from home twice in the morning at 7 am (30 minutes after arrival at the facility) and at 8 am. The interview also revealed that the staff made another bottle using facility’s formula and offered it to the child during lunch time at 12:30 PM. The interview revealed that the child refused all bottle that day and preferred solid food. Record review revealed that the child was offered a bottle during lunch time at 1:30 PM before went to sleep at 1:35 PM. Parent’s Interview revealed that children’s need for water and food, especially young children’s need for milk were properly met and the parent did not have any concerns
Report Continue on 809-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 53-CC-20241016092829
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KHAN, SHAZIA
FACILITY NUMBER: 393621889
VISIT DATE: 11/21/2024
NARRATIVE
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Moreover, it was also alleged that daycare child sustained unexplained injuries (Bruise on right forehead) while in care. Interview with licensee and staff revealed that children were properly supervised throughout the day. The interview also revealed that both licensee and staff did not observe any injury’s mark on the child nor see the child was injured at the facility. Record (picture taken)review did not show any injury on the child’s right forehead. Parent’s interview revealed that the children were properly supervised, and any injury would be informed to the parents. Interviewed parent did not has any concern regarding this.

Based on the information obtained throughout the course of this investigation the above allegations, LPA Tjhia determined that the complaint was found to be UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2