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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100835
Report Date: 11/15/2021
Date Signed: 11/15/2021 11:08:26 AM

Document Has Been Signed on 11/15/2021 11:08 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:KOHISTANNI, SHAFIQA FAMILY CHILD CAREFACILITY NUMBER:
376100835
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
11/15/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shafiqa KohistaniTIME COMPLETED:
11:30 AM
NARRATIVE
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On 11/15/2021 at 9:00 AM, Licensing Program Analyst (LPA) Adrian Mangina conducted an announced Pre-Licensing inspection with the applicant. Also present in the home during the inspection was Licensee’s husband Siraj Kohistani who provided translation. The two story three-bedroom, three-bathroom townhome was toured and inspected to ensure an environment safe for the care and supervision of children. A copy of the rental agreement was provided as proof of control of property.

Applicant will be using the following rooms for childcare: living room, kitchen, hallway, and first floor bathroom. The following areas will be off limits: back patio and all of second floor including bedroom #1, bedroom #2, bathroom #2, master bedroom and master bathroom. The off-limit areas either have safety latches, locks, doorknob covers or safety gates to prevent access. There are no bodies of water on the property.

The 2A10BC fire extinguisher located in the kitchen and and carbon monoxide detector located in living room meet requirements and are all operational. There is no working the smoke detector currently in the home. Applicant advised will need to obtain a smoke detector. All hazardous items were latched/locked and secured out of reach of children. There is a broken electrical outlet cover in living room which needs repair/replacement.

The applicant has sufficient safe, toys and equipment available. There is a phone on the premises. Outdoor play area is a neighborhood park. Visual supervision is required at all times.

(continued on LIC809 page 2)
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KOHISTANNI, SHAFIQA FAMILY CHILD CARE
FACILITY NUMBER: 376100835
VISIT DATE: 11/15/2021
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(LIC809 page 2)

Applicant states that they have sufficient financial resources to sustain the license. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Applicant rents the home and has provided the Landlord Notification Form. First Aid and CPR expire on 5/2023 and preventative health practices course was completed on 8/18/21. Mandated Reporter Training AB 1207 was completed on 7/24/21. Applicant has the required immunizations. Applicant states that there are no weapons in the home.

The new provider packet was reviewed with the applicant including information on ratios and capacity, child abuse reporting, children’s records, immunizations, adults living or working in the home, car seat law, shaken baby syndrome, SIDS, safe sleep practices, effects of lead poisoning, and the YMCA Resource Center. Applicant was reminded that corporal punishment, smoking, walkers, exersaucers, jumpers, and bouncy seats are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

LPA discussed and provided applicant with the following information:
· Child Care Advocates - email address [email protected].
· For common questions or questions regarding licensing requirements to contact the Child Care Licensing duty line at 619-767-2248.

Incidental Medical services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

(continued on LIC809 page 3)
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KOHISTANNI, SHAFIQA FAMILY CHILD CARE
FACILITY NUMBER: 376100835
VISIT DATE: 11/15/2021
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(LIC809 page 3)

Applicant has obtained landlord consent to care for up to 8 children, including any children living in the home ten years old and under

The following corrections are needed prior to the issuance of the license:

1) Install working smoke alarm
2) Repair/replace broken outlet cover next to TV in living room.

Applicant understands that corrections must be submitted to the Department within 30 days, no later than 12/14/21, or the application may be denied.

An exit interview was conducted with applicant. A copy of this report (LIC809) and appeal rights (LIC9058) was provided. Applicant’s signature is considered confirmation of receipt.
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
LIC809 (FAS) - (06/04)
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