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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 393623096
Report Date: 10/10/2024
Date Signed: 10/10/2024 11:32:18 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
05/20/2024 and conducted by Evaluator Carla Polanco Rivera
PUBLIC
COMPLAINT CONTROL NUMBER: 53-CC-20240520163443
FACILITY NAME:KHAN, SUMAILAHFACILITY NUMBER:
393623096
ADMINISTRATOR:KHAN, SUMAILAHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 268-5803
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:14CENSUS: 8DATE:
10/10/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Sumailah KhanTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal rights- Child sustained unexplained injury.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/10/24, Licensing Program Analysts (LPA) Carla Polanco Rivera met with the Licensee, Sumailah Khan to deliver the finding for the above allegation. Investigator Brianna Abeyta from the Department’s Investigations Branch conducted the investigation in conjunction with other outside agencies. During the investigation, Investigator conducted interviews with daycare staff, daycare parents, daycare children and staff at the medical facility where child #1 was treated for an injury that was alleged to have happened while child #1 was at the day care facility. Child #1 was unable to be interviewed due to age. Daycare parents and day care children who were interviewed revealed no concerns with the daycare. Medical and police records regarding the child who sustained the injury were also reviewed by the investigator. The information gathered from medical and police reports and interciews, as well as the information provided by daycare staff, daycare clients and the reporting party was conflicting. Due to a lack of evidence, the above allegation could not be proven or dis-proven. Therefore, the finding is unsubstantiated, meaning there was not a preponderance of evidence to prove or negate the allegation.

Report continued on LIC809-C...................
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Carla Polanco Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
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-20240520163443
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, SUMAILAH
FACILITY NUMBER: 393623096
VISIT DATE: 10/10/2024
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
26
27
28
29
30
31
32
 An exit interview was conducted with Licensee and Appeal Rights were provided. A Notice of Site Visit was posted by LPA and this shall be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Carla Polanco Rivera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2