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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624357
Report Date: 05/07/2025
Date Signed: 05/08/2025 08:38:55 AM

Document Has Been Signed on 05/08/2025 08:38 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SAFI, KARISHMAFACILITY NUMBER:
343624357
ADMINISTRATOR/
DIRECTOR:		KARISHMA, SAFIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 237-2910
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 14TOTAL ENROLLED CHILDREN: 21CENSUS: 0DATE:
05/07/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Karishma SafiTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On Wednesday, May 7, 2025 at 10:10 AM, Licensing Program Analyst (LPA) Tanya Washington met with Licensee, Karishma Safi, for the purpose of an unannounced annual/random inspection. Licensee speaks Pashto/ Dari, LPA Payenda Seddiqi provided translation over the phone during the inspection. Upon arrival Licensee and her minor sibling were present in the home, there were no other adults or children present during the inspection. All individuals subject to criminal background review have obtained a criminal record clearance. Facility hours of operation are Monday through Friday from 8:00 AM to 9:00 PM.

A health and safety evaluation was conducted in all areas accessible to children. Off limit areas in the home consist of entire upstairs and laundry room located on the first floor. LPA observed live cockroaches in the kitchen cabinets as well as under the kitchen sink. License stated that she will work with apartment management to get rid of the cockroaches. LPA also observed one dead cockroach on the kitchen counter near the stove. LPA observed a functioning smoke detector, carbon monoxide detector, and a full 2A10BC fire extinguisher. The facility has adequate toys that appear to be safe for children to use. The licensee stated there are no weapons or poisons in the home. There is no fireplace in the home. There is a pool in the apartment complex which is fenced according to Title 22 Regulations, per licensee she does not take the children to swim.

LPA reviewed twelve children’s files which were observed to be complete. Required postings and the children’s roster were observed. LPA observed that the last fire drill was documented November 22, 2024. Licensee’s CPR and First Aid certificate expires 10/2025. Licensee is exempt from Mandated Reporter Training due to language barrier. LPA observed four pack and plays in the home. Per Licensee she sets a timer on her phone every 15 minutes to check on sleeping infants, however she did not know she needed to document while the infants are asleep. LPA provided an Infant Safe Sleep Log which was produced by TSP program.

PAGE 1. REPORT CONTINUES ON LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Amanda Blesi
NAME OF LICENSING PROGRAM ANALYST: Tanya Washington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SAFI, KARISHMA
FACILITY NUMBER: 343624357
VISIT DATE: 05/07/2025
NARRATIVE
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LPA verified that the fees are current for the license. 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.

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.

Licensee understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the day. Licensee understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report/LIC 624 shall be submitted within 7 days to remain in compliance. Licensee understands that if any structural changes are made to the home; licensing must be notified PRIOR to construction. Licensee understands that if she wants to make any changes to OFF-limit areas to an ON-limit area, she must notify licensing and LPA must do an inspection BEFORE children are allowed in said area. Licensee understands that children’s records are to be maintained according to Title 22 regulations and be accessible to licensing for up to 3 years.

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/.


Page 2. REPORT CONTINUES ON LIC809C
NAME OF LICENSING PROGRAM MANAGER: Amanda Blesi
NAME OF LICENSING PROGRAM ANALYST: Tanya Washington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SAFI, KARISHMA
FACILITY NUMBER: 343624357
VISIT DATE: 05/07/2025
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

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.

A notice of site visit was given and must remain posted for 30 days. See LIC809D for deficiencies cited during the inspection. Exit interview conducted and report was reviewed with the licensee Karishma Safi. During the exit interview, the Licensee Karishma Safi, confirmed that there are no Registered Sex Offenders living in the facility. Appeal rights were provided and discussed.
NAME OF LICENSING PROGRAM MANAGER: Amanda Blesi
NAME OF LICENSING PROGRAM ANALYST: Tanya Washington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/08/2025 08:38 AM - It Cannot Be Edited


Created By: Tanya Washington On 05/07/2025 at 11:02 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SAFI, KARISHMA
FACILITY NUMBER: 343624357

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with the Licensee, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2025
Plan of Correction
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Licensee was provided a blank Infant Safe Sleep Log. Licensee stated that she will ensure to document infant naps going forward and will provide proof of correction to LPA by 06/09/2025 via e-mail tanya.washington@dss.ca.gov
Type B
Section Cited
CCR
102423(a)(2)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA pbserved live cockroaches in a kitchen cabinet located next to the stove. When the Licensee opened the cabinet LPA observed about 10 cockroaches crawl out of a plastic bag. LPA also observed a cockroach under the kitchen sink.
POC Due Date: 06/09/2025
Plan of Correction
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Licensee stated she will work on getting her apartment treated for cockraches and will provide proof of correction by POC date of 06/09/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Amanda Blesi
NAME OF LICENSING PROGRAM MANAGER:
Tanya Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025


LIC809 (FAS) - (06/04)
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