Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376624620
Report Date: 10/25/2016
Date Signed: 10/25/2016 09:38:08 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:ASTANZAI, ZAKIA & BENAFSHA FAMILY CHILD CAREFACILITY NUMBER:
376624620
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: DATE:
10/25/2016
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Zakia and Benafsha AstanzaiTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst, Carol Nakamura-Robinson arrived to the facility to follow up on complaint and during the course of this investigation, it was determined that a lack of care and supervision violation occurred wherein injuries occurred to a child. The licensee was not aware to how the infant sustained the bruising to his/her front and back. The infant is under the care of the licensee from 7 AM to approximately 7 PM and the parent picks up the child and noticed the bruising at 8:30 PM to 9 PM.

Based on the investigation, a citation was issued for lack of care and supervision.

See deficiency cited during this visit. See (LIC 809d) .

An exit interview was conducted and a copy of this report was given to licensee.
SUPERVISOR'S NAME: Carol AugustTELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Carol N RobinsonTELEPHONE: (619) 767-2215
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2016
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: ASTANZAI, ZAKIA & BENAFSHA FAMILY CHILD CARE
FACILITY NUMBER: 376624620
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2016
Section Cited
102417(a)
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Operation of a Family Child Care Home. The licensee shall be present in the home and shall ensure that children in care are supervised at all times. The licensee was not aware to how the child sustained the injuries to his/her body.
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The licensee agrees to provide a written statement to CCL to how she will ensure that this incident will not occur in the future by 10-26-16.
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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: Carol AugustTELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Carol N RobinsonTELEPHONE: (619) 767-2215
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2016
LIC809 (FAS) - (06/04)
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