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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 394500403
Report Date: 08/02/2022
Date Signed: 08/02/2022 03:52:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2022 and conducted by Evaluator Salene Mayberry
COMPLAINT CONTROL NUMBER: 53-CC-20220728143200
FACILITY NAME:KHAN, RABEEHAFACILITY NUMBER:
394500403
ADMINISTRATOR:KHAN, RABEEHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 331-4776
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:14CENSUS: 5DATE:
08/02/2022
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Rabeeh KhanTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Uncleared adult in the home
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salene Mayberry and Licensing Program Manager Bettina Engelman met with Licensee, Rabeeh Khan for the purpose of a complaint investigation regarding the above allegation.

During the vist Licensing Staff requested the facility roster and supporting documentation pertinent to the investigation. While touring the facility, Licensee revealed to Licensing Staff that her adult son was present in the home and that her adult daughter has been helping with care and supervision of daycare chidlren. A review of the fingerprint clearance showed that these individuals do not have a criminal record clearance. Based on a preponderance of evidence obtained the complaint regarding the above allegation was SUBSTANTIATED.

A Type A deficiency was cited on the subsequent page (LIC9099-D) of this report.

Report Continued on LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Salene Mayberry
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
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 4
Control Number 53-CC-20220728143200
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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, RABEEHA
FACILITY NUMBER: 394500403
VISIT DATE: 08/02/2022
NARRATIVE
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Upon receipt of Type A citations, Licensee shall post and provide copies of the LIC9099-D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Licensee must also keep the signed LIC9224, Acknowledging Receipt of LIC9099-D in each child's file

An Exit interview was conducted, and the report was reviewed and discussed with Licensee. Appeal Rights and a copy of the report was printed and provided to the Licensee. A Notice of Site Visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Salene Mayberry
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 53-CC-20220728143200
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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, RABEEHA
FACILITY NUMBER: 394500403
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/03/2022
Section Cited
CCR
102370d1
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102370 Criminal Record Clearance...(d)All individuals subject to a criminal record review...prior to working, residing or volunteering in a licensed facility (1)obtain a California clearance...
This requirement was not as evidenced by:
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Licensee stated that she had sent her uncleard adult son and daughter for their fngerprints and that she will ensure that their criminal background clearances are verified before they can return.
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On August 2, 2022, while children were in care, licensing staff learned that Licensee's adult son was present in the home and that her adult daughter has assisted her in providing care and supervision. This poses an immediate risk to the health and safety of children.
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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.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Salene Mayberry
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4