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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100835
Report Date: 11/18/2022
Date Signed: 11/18/2022 04:59:43 PM

Document Has Been Signed on 11/18/2022 04:59 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, 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: 17CENSUS: 1DATE:
11/18/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Siraj Koshistani and Shafiqa KohistanniTIME COMPLETED:
05:20 PM
NARRATIVE
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On 11/18/22 at 1:30PM Licensing Program Analyst (LPA) Patrick Ma conducted a Case management inspection for an increase in capacity. Upon arrival, Licensee was not home. LPA was greeted by three minor children, stating they were Licensee’s children and a man outside nearby later was identified as adult son, Naseerulla Kohistani. Adult son permitted LPA to inspect the home and soon after, husband Siraj Kohistani arrived home as well. About 1:48PM, Licensee Shafiqa Kohistanni, came home with one day care child, stating they were at the park. Husband help translate during inspection. The 2 story home was toured and inspected to ensure an environment safe for the care and supervision of children. During inspection visit only one infant daycare child was present.

On 9/7/22, the licensee submitted an application (LIC 279) to request an increase of capacity. The Fire Safety Inspection Request (STD 850) was approved by the local fire marshal and granted the capacity increase to fourteen (14) children on 9/20/22 and emailed report to the Department on 10/11/22.

The 3 bedroom, 3 bathroom home was toured and inspected to ensure an environment safe for the care and supervision of children. Licensee uses the living room, kitchen, and first floor bathroom for child care. Off limit areas are entire upstairs and back patio and is made inaccessible with a gate for stairs and sliding door lock. Licensee was advised to provide visual supervision at all times when children are outdoors.

The fire extinguisher, carbon monoxide detector, and smoke detector meet requirements and are operational. All hazardous items were latched/locked and made secured out of reach of children during the inspection. There are no bodies of water on the property. Applicant states that there are no weapons in the home. Children and helper records were reviewed.

LPA provided 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.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Patrick Ma
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 11/18/2022 04:59 PM - It Cannot Be Edited


Created By: Patrick Ma On 11/18/2022 at 02:14 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: KOHISTANNI, SHAFIQA FAMILY CHILD CARE
FACILITY NUMBER: 376100835

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2022
Section Cited
CCR
102417(g)(4)

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102417(g)(4) Operation of a Family Child Care Home: Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement was not met as evidenced by:
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Licensee latched and made all hazards inaccessible during the inspection visit. POC is cleared.
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Based on observation, Licensee had knives in kitchen drawer, cleaning solutions under the bathroom sink, and dish washing liquid on the bathroom floor, all accessible to children. This posses an immediate hazard to the health and safety of children in care.
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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:Renesha Askew
LICENSING EVALUATOR NAME:Patrick Ma
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


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Document Has Been Signed on 11/18/2022 04:59 PM - It Cannot Be Edited


Created By: Patrick Ma On 11/18/2022 at 02:31 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: KOHISTANNI, SHAFIQA FAMILY CHILD CARE
FACILITY NUMBER: 376100835

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/25/2022
Section Cited
HSC
1596.841

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1596.841 Current roster of children provided care in facility required
Each child day care facility shall maintain a current roster of children who are provided care in the facility...
This requirement is not met as evidenced by:
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Licensee completed children's roster during inspection visit. POC is cleared.
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Based on interview and file review, the licensee stated she has 17 children enrolled in care but had no Childrens Roster which poses a potential health and safety risk to persons in care.
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Type B
11/25/2022
Section Cited
CCR102421(a)

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102421(a) Childs Records. The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).
This requirement was not met as evidenced by:
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Licensee and husband stated they will submit proof of all signed documents by 11/25/22 and corrected DOB in children's files during inspection visit.
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Based on file review, Licensee did not have signed children's documents for 4 of 15 children enrolled. Also, a separate 4 of 15 childrens files had all the same birthdays on their LIC 700 that did not match any enrolled children. This poses a potential hazard to the health and safety of children in care.
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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:Renesha Askew
LICENSING EVALUATOR NAME:Patrick Ma
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


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Document Has Been Signed on 11/18/2022 04:59 PM - It Cannot Be Edited


Created By: Patrick Ma On 11/18/2022 at 03:00 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: KOHISTANNI, SHAFIQA FAMILY CHILD CARE
FACILITY NUMBER: 376100835

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/25/2022
Section Cited
CCR
102418(a)

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102418 Immunizations: Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations. This requirement was not met as evidenced by:
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Licensee and husband stated, they will submit proof of the 8 missing children's immunizations to LPA by 11/25/22 or removed the children from care.
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Based on recoreds review, 8 of the 15 children's files did not have children's immunizations on file.
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Type B
11/25/2022
Section Cited
HSC1596.8662(b)(1)

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1596.8662(b)(1) …a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training. This requirement was not met as evidenced by:
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Licensee and husband stated they will submit proof of completed mandated reporter certificate (https://mandatedreporterca.com/) by 11/25/22.
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Based on records review and interview, husband stated he helps his wife/Licensee with child care. Hisband/helper is missing mandated reporter certificate.
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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:Renesha Askew
LICENSING EVALUATOR NAME:Patrick Ma
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


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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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KOHISTANNI, SHAFIQA FAMILY CHILD CARE
FACILITY NUMBER: 376100835
VISIT DATE: 11/18/2022
NARRATIVE
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Licensee was reminded of the staffing/capacity ratios for Large Family Child Care Homes. Twelve (12) children, no more than 4 infants (birth to 24 months) and 8 older children over the age of 2. A qualified assistant (age 14 or older) is required. For fourteen (14) children, no more than 3 infants (birth to 24 months) and 11 older children; at least 2 school age, 1 child at least age 6, 1 child enrolled in and attending kindergarten or elementary school. Landlord consent and written parent notification are required when caring for more than 12 children. When there isn't a qualified assistant, licensee must follow Small Family Home Child Care Regulations.

Provider is hereby reminded of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms; corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA reviewed Covid-19 guidelines with Licensee and provided Covid-19 resources. LPA directed Licensee to website: https://www.cdss.ca.gov/inforesources/community-care-licensing to receive important updates and information. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

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.
Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Childcare Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed and provided Licensee with the following: childcare advocates-email address: [email protected] . In addition, for general questions or questions regarding licensing requirements contact the Childcare Licensing Duty Line at (619) 767-2248.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Patrick Ma
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
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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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KOHISTANNI, SHAFIQA FAMILY CHILD CARE
FACILITY NUMBER: 376100835
VISIT DATE: 11/18/2022
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Childcare 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 Childcare Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

See 809D for deficiency cited. Deficiency need to be cleared before approval for increase capacity license can be granted.

Deficiencies need to be cleared by Plan of Correction date or civil penalties can be assessed and/or denial of increase capacity application.

Exit interview conducted and report was reviewed with the applicant Shafiqa Kohistanni. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Patrick Ma
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
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