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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415968
Report Date: 05/09/2024
Date Signed: 05/09/2024 04:22:58 PM

Document Has Been Signed on 05/09/2024 04:22 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:KHAN, SHAHANAFACILITY NUMBER:
013415968
ADMINISTRATOR/
DIRECTOR:		KHAN, SHAHANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 489-5350
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
05/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Shahana Khan- LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 5/9/24 at 11:50am, LPA Plumboy met with licensee Shahana Khan for the another purpose, which resulted in a case management inspection. LPA Plumboy found other regulations violated other then her purpose at the facility through interviews and record review. Present during the inspection was 9 children in care (1 infant and 8 preschool age children) and fingerprint clear and associated assistants Milagros Hildago and Amelia Medina.

The following was found:
1. Personal Rights due to an assistant arguing with other staff in front of children in care
2. Incomplete roster
3. Conduct inimical
4. Missing Assistant files
5. 2 assistants present without criminal record clearances, civil penalty assessed

As a result of the citations, licensee will complete the live virtual FCCH orientation on 6/12/24 by registering online by 5:00pm on 5/10/24, and submitting proof of registration to LPA Plumboy. Once the orientation is completed, Licensee Shahana Khan will submit her orientation certificate to LPA Plumboy via email.

The attached Type A deficiency is cited today. The Type A deficiency is cited regarding 2 criminal record clearance. A civil penalty for each adult in the amount of $500 each is being assessed. Upon receipt, licensee shall post for 30 days and provide copies of this licensing report to parent/guardians of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 Acknowledgement of Receipt of Licensing Reports should be signed by guardians and placed in each child’s file.

See 809-D for deficiencies cited during today's inspection. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Appeal rights provided and discussed. Exit interview conducted.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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 05/09/2024 04:22 PM - It Cannot Be Edited


Created By: Briana Plumboy On 05/09/2024 at 12:29 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: KHAN, SHAHANA
FACILITY NUMBER: 013415968

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
102423(a)(1)

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To be treated with dignity in his/her personal relationship with staff and other persons.
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Licensee will complete the live virtual FCCH orientation on 6/12/24 by registering online by 5:00pm on 5/10/24 and submitting proof of registration to LPA Plumboy. Once the orientation is completed, Licensee Shahana Khan will submit her orientation certificate to LPA Plumboy via email.
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Based on interviews, an assistant whom is no longer employed at the facility argued with other staff in front of children in care which poses a potential health and safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Type B
05/17/2024
Section Cited
CCR102416.1(d)

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All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review.
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Licensee will complete the live virtual FCCH orientation on 6/12/24 by registering online by 5:00pm on 5/10/24 and submitting proof of registration to LPA Plumboy. Once the orientation is completed, Licensee Shahana Khan will submit her orientation certificate to LPA Plumboy via email.
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Based on record review, 2 assistants whom are no longer employed at the facility did not have staff files which poses a potential health and safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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:Wynn Norona
LICENSING EVALUATOR NAME:Briana Plumboy
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2024 04:22 PM - It Cannot Be Edited


Created By: Briana Plumboy On 05/09/2024 at 03:20 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: KHAN, SHAHANA
FACILITY NUMBER: 013415968

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
102417(g)(8)

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Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.This requirement was not met as evidenced by:
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On or before 5/15/24, licensee will provide LPA Plumboy with a roster (Lic.9040) containing all information for all children who have been enrolled in her childcare in the past 3 years.
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Based on interview and record review, the license's facility roster is incomplete. By having an incomplete roster, this poses a potential health and safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Type B
05/17/2024
Section Cited
HSC1596.885(c)

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Conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the
facility or the people of this state.
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On or before 5/17/24, licensee agreed to write a statement about being honest in all her dealings with the Department.
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Based on interview and record review, the licensee was not honest with LPA Plumboy about a former employee which poses a potential health and safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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:Wynn Norona
LICENSING EVALUATOR NAME:Briana Plumboy
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


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Document Has Been Signed on 05/09/2024 04:22 PM - It Cannot Be Edited


Created By: Briana Plumboy On 05/09/2024 at 03:34 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: KHAN, SHAHANA
FACILITY NUMBER: 013415968

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2024
Section Cited
HSC
1596.871(c)(1)(A)

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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.
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Licensee will complete the live virtual FCCH orientation on 6/12/24 by registering online by 5:00pm on 5/10/24 and submitting proof of registration to LPA Plumboy. Once the orientation is completed, Licensee Shahana Khan will submit her orientation certificate to LPA Plumboy via email.
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This requirement is not met as evidenced by: There was 2 assistants present at the childcare caring for children whom did not obtain criminal record clearances prior to being in the presence of children in care which poses an immediate health and safety risk to children in care.
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Today a civil penalty for the amount of $1000 is being assessed.
Lic.9224 shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months.

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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:Wynn Norona
LICENSING EVALUATOR NAME:Briana Plumboy
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


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