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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100835
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:11:05 PM

Document Has Been Signed on 02/23/2023 03:11 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: 8CENSUS: DATE:
02/23/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shafiqa KohistanniTIME COMPLETED:
03:15 PM
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On 2/23/2023 at 2:00PM Licensing Program Manager (LPM), Renesha Askew and Licensing Program Analyst (LPA), Patrick Ma conducted an office meeting with Licensee, Shafiqa Kohistanni. Also, in attendance was husband/helper Siraj Kohistani to help translate in Licensee’s primary language, Poshto. The purpose of this meeting is to discuss deficiencies cited on 11/18/2022 as well as concerns mentioned by licensee spouse in prior visit to Office on 12/14/2022 prior to issuing increase of capacity license.

On 11/18/22 Licensee received the following citations:
Type A
• 102417(g)(4) Operation of a Family Child Care Home: Hazards accessible to child in kitchen and bathroom
Type B
• Health and Safety Code 1596.841 : Licensee did not maintain children’s roster
• 102421(a) Childs Records: All children’s files were missing required documents
• 102418(g) Immunizations: Immunizations records were missing from children’s files
• Health and Safety Code 1596.8662(b)(1): Helper was missing Mandated Reporter Certificate

Licensee has cleared all Plan of Corrections by making all hazardous items inaccessible during the inspection and provided the Department with all missing children’s documents including their immunizations on 11/22/22.

Attempted visits were made to the facility on 12/9/22, 1/12/23, and 1/12/23 to verify corrections and to address concerns from Licensee spouse. Licensee and husband reported she left the country from 1/12/23 and returned 2/12/23, but the husband/helper would continue childcare.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Patrick Ma
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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 2
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: 02/23/2023
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At the time of notification, Licensee and husband were advised of title 22 regulation Section 102416(c) requirement stating: “The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.”.

During this meeting Licensee was provided with a copy of form LIC 311D as well as title 22 Section 102391 Inspection Authority of the Department as well as reminded of the requirement of having a working telephone and responding to attempts at contact by phone or in person in a timely manner. The need to foster a good working relationship with each other at all times by ensuring a professional tone and demeanor by Licensee, residents, as well as the Department was also discussed.

Licensee was also provided with the CDSS Child Care Licensing (CCL) Family Child Care Providers Resource link with instructional videos: https://ccld.childcarevideos.org/family-child-care-providers/. It is recommended for Licensee to review the videos including, but not limited to: “Locks and Inaccessibility Requirements in Child Care?”, “Record Keeping in Family Child Care”, and “Health and Safety Training”. Licensee states she understands that she needs to abide by Health and Safety Code and Title 22 Regulations in the operation of her Family Child Care Home. A Technical Support Program (TSP) referral will be submitted today, 2/23/23, on Licensee’s behalf and a copy of the TSP brochure was provided. For questions related to TSP, email: [email protected]

Licensee was advised to regularly visit the Community Care Licensing WEB SITE: www.ccld.ca.gov for quarterly updates and regulation and sign up to receive Provider Information Notices (PIN's). During meeting licensee was provided the Duty Line: 619-767-2248 who is available to assist Monday – Friday 8am-5pm.

Licensee states she understands that she needs to abide by Health and Safety Code and Title 22 Regulations in the operation of her Family Child Care Home. The request for increase in Capacity from 8 to 14 will be granted today.

Exit interview conducted and report was reviewed with the licensee Shafiqa Kohistanni.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Patrick Ma
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC809 (FAS) - (06/04)
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