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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312946
Report Date: 08/04/2021
Date Signed: 08/04/2021 10:41:05 AM

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:IBRAHIM, ALIAFACILITY NUMBER:
304312946
ADMINISTRATOR:IBRAHIM, ALIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 931-7469
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY:14CENSUS: 13DATE:
08/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee Alia IbrahimTIME COMPLETED:
10:30 AM
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On 08/04/2021, Licensing program manager (LPM) Thuy Ho and Licensing program analyst (LPA) Tina Nguyen conducted a case management visit to issue an amended complaint investigation report from the complaint investigation report dated August 3, 2021. LPM Ho and LPA Nguyen met with licensee Alia Ibrahim and toured the facility. LPM and LPA observed 3 infants, 5 preschool children and 5 school-age children with 3 staff members including the licensee. 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 index clearances or exemptions.

Please see "amended" report dated 08/03/2021 for correction.

After a tour of a facility, no deficiency was observed

Exit interview was conducted. The notice of site visit was posted. Licensee was informed the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalty of $100.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Tina NguyenTELEPHONE: (714) 292-2922
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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