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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422337
Report Date: 05/04/2022
Date Signed: 05/04/2022 11:27:35 AM

Document Has Been Signed on 05/04/2022 11:27 AM - 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:SHAH, HINAFACILITY NUMBER:
013422337
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 7CENSUS: 4DATE:
05/04/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Hina ShahTIME COMPLETED:
11:40 AM
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On May 4, 2022 at approximately 10:40am, LPA Haderer arrived unannounced for a Plan of Correction meeting with Licensee Hina Shah. The visit was to ensure the correct ratio of children were in care.

Present today upon arrival was the licensee, her fingerprint and TB tested husband and 4 children in care (3 infants and 1 two-years old). The home is in ratio today.

Licensee viewed the "How Many Children Can Attend a Family Child Care Home?" at WWW.CCLD.CHILDCAREVIDEOS.ORG. and submitted an email acknowledging a statement of understanding. Licensee has provided a copy of the Type A deficiency to all the children's parents and collected their signatures and dates on the LIC9224 Acknowledgement of Receipt of Licensing Reports form. The forms are in the children's files. The deficiency is cleared today.

Also, Licensee has mailed her application for a Large Family child care home. This will be processed as quickly as possible so the licensee can expand her care.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Hina Shah.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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