434416813-6-12-2024-07-CC-SYIP-D66VDH-20240612162046

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416813
Report Date: 06/12/2024
Date Signed: 06/12/2024 04:20:58 PM

Document Has Been Signed on 06/12/2024 04:20 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	KHANALI, SHABNAM		FACILITY NUMBER:	434416813
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 3	CENSUS: 3	DATE:	06/12/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:28 PM
MET WITH:	Shabnam Khanali		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

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	Licensing Program Analysts (LPAs) Samantha Yip and Jennifer Beehler conducted an unannounced Annual/Random inspection. LPAs met with Licensee Shabnam Khanali and explained the reason for the inspection. The purpose of this inspection is Licensee also applied for a large Family Child Care Home (FCCH). Licensee has at least one year of experience as a small FCCH provider to apply for a large FCCH. A fire clearance was granted on 06/03/2024. An updated LIC 9149 is on file. The hours of operation are Monday through Friday 7:30AM to 5:30PM. There is area is to post required, license and notification of parents rights. Licensee uses her cell phone. Licensee does have daycare insurance. LPAs toured the inside of the home with Licensee. The off-limit areas inside of the home are the master bedroom, master bathroom, and kitchen. There is a detached garage, which is also off-limits. LPA discussed with Licensee that any areas that area that are off-limit needs to be inaccessible. Disinfectant, cleaning supplies, and other items that could pose a risk to children were inaccessible. LPA discussed with Licensee that any medication and anything that states to keep out of reach of children, such as Swifter wipes, needs to be inaccessible to children. There is a fire extinguisher, smoke detector, and carbon monoxide detector. The last fire/disaster drill was conducted on 06/06/2024. Licensee stated that there are no weapons, such as firearms, stored on the premise. Licensee uses the bedroom next to the bathroom to isolate any sick children. There is toys for children. The backyard is used and is fenced. There are toys for children. There were no bodies of water observed during today's inspection. LPA discussed with Licensee about putting a gate to block the AC unit. -------------------continues on 809 dated 06/12/2024 page 2-----------------------

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KHANALI, SHABNAM	FACILITY NUMBER: 434416813
	VISIT DATE: 06/12/2024

NARRATIVE

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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. LPA discussed with Licensee that the 15 minute sleep check is required for all infant (birth to 24 months). Licensee stated that she stop documenting the 15 minute sleep check.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee does not transport children, but understands that children cannot be left alone and unattended in parked vehicles. Licensee provides meals and snacks to children. Licensee understands that if children bring food from home that the container needs to have the child's name on it.

A copy of the facility roster was obtained. Three (3) children's files were reviewed during today's inspection. The records reviewed include but not limited to parent's rights and immunization records. LPA discussed with Licensee that all immunization records need to be transcribed onto the immunization card.

Licensee has a valid CPR/1st Aid, which expires on 03/2025. Licensee completed the Mandated Reporter training on 02/25/2023 and was reminded that training requires renewal every two years. Licensee's immunization records for measles, pertussis, and influenza are on file; along with her Preventive Health and Safety certificate.
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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KHANALI, SHABNAM	FACILITY NUMBER: 434416813
	VISIT DATE: 06/12/2024

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The adults 18 and over living in the home are Licensee and her brother. All adults have cleared criminal record, child abuse index, and TB. 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.

During the exit interview, the LICENSEE, Shabnam Khanali, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

LPA discussed with Licensee about the maximum capacity requirement of a Large Family Child Care Home License. The maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home shall be either:
(1) 12 children, no more than four of whom may be infants; or
(2) more than 12 and up to 14 children if at least one child is enrolled in and attending kindergarten or elementary school an a second child is at least six years of age and there are no more than three infants being cared for during any time when more than 12 children are being cared for.

When Licensee have more than 12 and up to 14 children in the home, Licensee must notify the parent using the form LIC9150 “Parent Notification Additional Children in Care." LPA reminded Licensee that when Licensee does not have a Helper, Licensee can only care for up to 8 children at any one time in the home.
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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KHANALI, SHABNAM	FACILITY NUMBER: 434416813
	VISIT DATE: 06/12/2024

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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.

Licensee will submit the following by 06/21/2024:
- AC unit is gated off

As a result of this inspection, a Type B citation was issued. Exit interview conducted and report was reviewed with Licensee Shabnam Khanali. A notice of site visit has been issued and must remain posted for 30 days. Licensee was advised that upon review and approval of Licensing Program Manager a license for a large FCCH will be granted and issued.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/12/2024 04:20 PM - It Cannot Be Edited

Created By: Samantha Yip On 06/12/2024 at 03:39 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KHANALI, SHABNAM	FACILITY NUMBER: 434416813
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in three out of three persons, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/21/2024
	Plan of Correction
1 2 3 4	By POC 06/21/2024, Licensee will document the child's name, date, and time child is checked. Licensee submit proof to Licensing.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Joel Segura

LICENSING EVALUATOR NAME:

Samantha Yip

LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC809 (FAS) - (06/04)

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