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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312883
Report Date: 11/10/2020
Date Signed: 11/10/2020 02:27:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:KHAMIS, NAJWA JOSEPHFACILITY NUMBER:
304312883
ADMINISTRATOR:KHAMIS, NAJWA JOSEPHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 313-5655
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY:14CENSUS: 10DATE:
11/10/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Licensee Najwa J Khamis TIME COMPLETED:
02:45 PM
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An unannounced case management report was initiated on today’s date by Licensing Program Analyst (LPA’s) Barajas and Odom, during an Investigation, records reviewed of the staff and interviews. LPA’s discovered that an individual: John Jiries was not associated to the facility.

During today's inspection there were 4 infants, 6 preschool age children with Licensee Najwa Joseph Khamis and Assistant Nadia Abdelahad in day care area. A minor assistant was also present in the home upstairs in an off-limit room. A review of adult records indicates that all facility residents, staff or other individuals who require caregiver background checks do not have criminal record and child abuse index clearances or exemptions, Licensee cousin John Jiries was in the childcare area alone with the children in care upon LPA’s arrival at 10:22a.m.

Upon arrival at 10:22a.m., LPA’s observed Licensee outside in the front yard on the phone. As LPA’s walked up to the facility the assistant was observed being in the kitchen, minor assistant was upstairs, and uncleared adult was in day care room alone with children. Based on the interviews conducted with Licensee, and adults all stated John Jiries was at the facility dropping of grandmother Nadia Abdelahad at 9a.m. and was helping Licensee Najawa J. Khamis move some plants around the home. LPA Barajas visually observed John Jiries interacting with day care children alone in day care room upon arrival. LPA Barajas was able to visually observe through opened front screen door, while Assistant was caring for a child in family room area and Licensee was answering the door. LPA visually observed uncleared adult shadow through sliding door in day care room that was approximately 20 ft away from front door.

Licensee will be cited for Criminal Record violation, Type A for: John Jiries, California Code of Regulations, Title 22, Division 12, Chapter 1, Section 102370(d)(1) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department; Therefore is being cited on the attached LIC 809D.


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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KHAMIS, NAJWA JOSEPH
FACILITY NUMBER: 304312883
VISIT DATE: 11/10/2020
NARRATIVE
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Page 2, Continued from Page 2

A civil penalty of $100 has been assessed for: John Jiries.

Based on observation and pictures taken upon entrance into the facility the stairway was located on the right side of the entrance. The baby gate was not secure, and it was hanging on from another metal rail attached to the wall which was also not properly secured or locked.

Licensee will be cited a Type B for Operation of Family Child Care Home. California Code of Regulations, Title 22, Division 12, Chapter 1, Section 102417(g)(3) (g). The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to: (3) Where children less than five years old are in care, stairs shall be fenced or barricaded. Operation of a Family Child Care Home is being cited on the attached LIC 809D.

This report cites a Type A violation and shall be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC 9224 to be kept in each child's file.

Exit interview was conducted. Notice of Site Visit was posted during the visit. Licensee was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above

End of Report

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KHAMIS, NAJWA JOSEPH
FACILITY NUMBER: 304312883
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2020
Section Cited

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102370(d)(1) Criminal Record Clearance. (d)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing...:(1) Obtain a California clearance or a criminal record exemption as req...
This requirement is not met as evidenced by:
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Based on observation and interview licensee failed to ensure cousin John Jiries has fingerprint clearance. Uncleared adult was visually observed in day care room alone with children upon LPA's arrival at 10:22am on todays date. This poses an immediate risk 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: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KHAMIS, NAJWA JOSEPH
FACILITY NUMBER: 304312883
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2020
Section Cited

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102417(g)(3) Operation of a Family Child Care Home:(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to:(3) Where children less than five years old are in care, stairs shall be fenced or barricaded.This requirement is not met as evidenced by:
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Based on observation and interview and pictures taken upon entrance into the facility the stairway was located on the right side of the entrance. The baby gate was not secure, and it was hanging on from another metal rail attached to the wall which was also not properly secured or locked. This is a potential risk to the 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: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4