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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621889
Report Date: 05/07/2024
Date Signed: 05/07/2024 03:59:50 PM

Document Has Been Signed on 05/07/2024 03:59 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KHAN, SHAZIAFACILITY NUMBER:
393621889
ADMINISTRATOR/
DIRECTOR:		KHAN, SHAZIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 263-9371
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
05/07/2024
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:31 PM
MET WITH:Shazia KhanTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erwin Tjhia and Licensing Program Manager (LPM) Karyn Guerra conducted an unannounced inspection and met with Licensee, Shazia Khan. LPA observed 14 children supervised by Licensee and Staff. The facility is open 24/7.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. LPA observed an individual, who does not have criminal record clearance, was present and caring for children during today's visit.

LPA and Licensee toured the facility during the inspection. Off limit areas are the entire master bedroom/bathroom, laundry room, and garage. Off limit areas are being made inaccessible by closed locked doors and baby gates. The backyard is fenced. Licensee stated there are no weapons in the home. There are no bodies of water on the premises. During the visit, Licensee left the facility at 2:05 PM to pick up her own child from school and returned to the facility at 2:35 PM

LPA conducted record reviews during the inspection. Seven children's files and Licensee's files were reviewed. LPA discussed mandated reporter training with the Licensee. Licensee has current Mandated Reporter Training on file. Licensee understands Mandated Reporter Training is to be completed every two years. Mandated reported will be expired on 08/2024. Mandated reporter training can be accessed at www.mandatedreporterca.com. CPR/First Aid certification was reviewed for Licensee. Certification expiration date is 03/2025. LPA did not observed fire drills that were need to be conducted at least once every six months and documented.

Report Continue on 809-C.
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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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Document Has Been Signed on 05/07/2024 03:59 PM - It Cannot Be Edited


Created By: Erwin Tjhia On 05/07/2024 at 03:07 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KHAN, SHAZIA
FACILITY NUMBER: 393621889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as LPA observed an individual, who does not have criminal record clearance, was present and caring for children during today's visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
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Licensee stated that she will fingerprint the staff, and the staff will no return until the fingerprint is cleared and associated to the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karyn Guerra
LICENSING EVALUATOR NAME:Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/07/2024 03:59 PM - It Cannot Be Edited


Created By: Erwin Tjhia On 05/07/2024 at 03:07 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KHAN, SHAZIA
FACILITY NUMBER: 393621889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in as LPA did not observed the fire drill was conducted and documented which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2024
Plan of Correction
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Licensee will conduct the fire drill and document it. Licensee will submit the documentation to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karyn Guerra
LICENSING EVALUATOR NAME:Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/07/2024
NARRATIVE
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LPA observed that there were no hazardous items accessible to children. LPA observed that cleaning materials were inaccessible. Fire extinguisher, smoke detector, and carbon monoxide detector meet regulation. Toys appear to be safe. Licensee stated there are no weapons in the home.

This facility does not provides Incidental Medical Services – IMS. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

LPA discussed the safe sleep regulations with licensee 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 licensee 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. In addition, LPA discussed the infant sleep regulations with licensee. LPA observed 15 minutes infant napping logs for infants 24 months and under. LPA observed the LIC 9227 Individual Sleeping Plan, for infants under 12 months, for licensee during today's inspection.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

On this date, 04/26/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Report Continue on 809-C

SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/07/2024
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

In the areas that were evaluated, a Type A deficiency and a Type B deficiency were cited during today’s inspection.



Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files.

An Exit interview was conducted, and the report was reviewed with Licensee, Shazia Khan. LPA posted a notice of site visit. Licensee understands the Notice must remain posted for 30 days and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.

SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC809 (FAS) - (06/04)
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