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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621889
Report Date: 05/01/2023
Date Signed: 05/01/2023 02:57:00 PM

Document Has Been Signed on 05/01/2023 02:57 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:KHAN, SHAZIAFACILITY NUMBER:
393621889
ADMINISTRATOR:KHAN, SHAZIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 263-9371
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
05/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Shazia KhanTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erwin Tjhia and Licensing Program Manager (LPM) Bettina Engelman, met with the licensee, Shazia Khan, for a Case Management Inspection.

When LPA and LPM arrived at the facility at 11:20 AM, Licensee was not present. She arrived several minutes later and entered the home with the licensing's staff. Inside the facility, there was an assistant caring for 12 children. LPA and LPM toured the facility and observed 3 of the children were in garage which is an off-limit area. The fence in the back yard has an opening leading to the pool area under construction. The pool belong to the house behind the facility.

Title 22 Deficiencies have been cited on the attached LIC 809D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files.

This report was reviewed and discussed with licensee. A notice of site visit and appeal rights were provided
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Erwin Tjhia
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2023
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 3
Document Has Been Signed on 05/01/2023 02:57 PM - It Cannot Be Edited


Created By: Erwin Tjhia On 05/01/2023 at 02:09 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: KHAN, SHAZIA
FACILITY NUMBER: 393621889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/02/2023
Section Cited
CCR
102416.5e

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Staffing Ratio and Capacity: If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).
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Licensee stated that she is aware of the capacity regulation. Licensee stated that she was only gone for few minutes. LPA will return to verify compliance.
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This requirement was not met as evidenced by: Licemsee's assistant was left alone with 12 daycare children, including 4 infants.
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Request Denied
Type A
05/02/2023
Section Cited
CCR102417.(g)(6)

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(6) Outdoor play areas shall be either fenced, or outdoor play shall be supervised by the licensee or caregiver.
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Licensee stated that she was in the process of installing a gate. The gate was completed during today inspection.
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This requirement was not met as evidenced by: LPA observed an opening in the backyard fence leading to the pool area under construction of the house behind the facility..
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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:Bettina Engelman
LICENSING EVALUATOR NAME:Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/01/2023 02:57 PM - It Cannot Be Edited


Created By: Erwin Tjhia On 05/01/2023 at 02:22 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: KHAN, SHAZIA
FACILITY NUMBER: 393621889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited
CCR
102416.3(a)(6)

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(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: .(6) Any change from an area of the family child care home previously
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The licensee stated that she will not have the children playing in the garage. The licensee also will remind her staff that the children will not be allowed in the garage. The LPA will return to conduct inspection to verify compliance.
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 identified as "off limits" to an area where careand supervision will be provided to children in care. This requirement was not met as evidenced by : LPA observed 3 children at off limit garage which was set up with toys and tv.
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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:Bettina Engelman
LICENSING EVALUATOR NAME:Erwin Tjhia
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


LIC809 (FAS) - (06/04)
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