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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 013415968
Report Date: 06/06/2024
Date Signed: 06/06/2024 09:42:33 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2024 and conducted by Evaluator Briana Plumboy
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20240417104416
FACILITY NAME:KHAN, SHAHANAFACILITY NUMBER:
013415968
ADMINISTRATOR:KHAN, SHAHANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 489-5350
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:14CENSUS: 9DATE:
06/06/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Shahana Khan- LicenseeTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights- Staff member handles daycare children in a rough manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/6/24, Licensing Program Analyst (LPA) Briana Plumboy met with licensee Shahana Khan to deliver the finding of an complaint filed against a facility staff regarding the allegation of staff member handles daycare children in a rough manner. Present for the inspection was licensee, licensees fingerprint cleared and associated husband, fingerprint clear and associated assistant Amelia Medina, and 9 children in care.
Based on interviews conducted and observations, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED.
A notice of site visit was given and must remain posted for 30 days.
Appeal Rights were given and discussed. An exit interview was conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2024 and conducted by Evaluator Briana Plumboy
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20240417104416

FACILITY NAME:KHAN, SHAHANAFACILITY NUMBER:
013415968
ADMINISTRATOR:KHAN, SHAHANAFACILITY TYPE:
810
ADDRESS:31519 SILVERTIDE DRIVETELEPHONE:
(510) 489-5350
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:14CENSUS: 9DATE:
06/06/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Shahana Khan- LicenseeTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights- Staff did not provide a safe and comfortable environment for day-care children
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/6/24, Licensing Program Analyst (LPA) Briana Plumboy met with licensee Shahana Khan to deliver the finding of an complaint filed against a facility staff regarding the allegation of staff did not provide a safe and comfortable environment for day-care children. Present for the inspection was licensee, licensees fingerprint cleared and associated husband, fingerprint clear and associated assistant Amelia Medina, and 9 children in care.
Based on interviews conducted and observations, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED.
A notice of site visit was given and must remain posted for 30 days.
Appeal Rights were given and discussed. An exit interview was conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2024 and conducted by Evaluator Briana Plumboy
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20240417104416

FACILITY NAME:KHAN, SHAHANAFACILITY NUMBER:
013415968
ADMINISTRATOR:KHAN, SHAHANAFACILITY TYPE:
810
ADDRESS:31519 SILVERTIDE DRIVETELEPHONE:
(510) 489-5350
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:14CENSUS: 9DATE:
06/06/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Shahana Khan- LicenseeTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights- Staff member verbally abuses daycare children
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/6/24, Licensing Program Analyst (LPA) Briana Plumboy met with licensee Shahana Khan to deliver the finding of an complaint filed against a facility staff regarding the allegation of staff member verbally abuses daycare children. Present for the inspection was licensee, licensees fingerprint cleared and associated husband, fingerprint clear and associated assistant Amelia Medina, and 9 children in care.
Based on interviews conducted and observations, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED.
A notice of site visit was given and must remain posted for 30 days.
Appeal Rights were given and discussed. An exit interview was conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3