376100222-1-3-2020-51-CC-TBLK-BKH265-20200103160635

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376100222
Report Date: 01/03/2020
Date Signed: 01/03/2020 04:06:51 PM

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:	MOHAMED, SAMSAM FAMILY CHILD CARE		FACILITY NUMBER:	376100222
ADMINISTRATOR:	SAMSAM MOHAMED		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(619) 436-6344
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92119
CAPACITY:	14	CENSUS: 0	DATE:	01/03/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Samsam Mohamed		TIME COMPLETED:	04:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Tyra Block, conducted an announced Pre-Licensing inspection with the applicant. The single story home was toured and inspected to ensure an environment safe for the care and supervision of children. Applicant rents the home. Facility hours of operation are Monday through Friday, 24 hours. The fire extinguisher and smoke detector meet requirements and are operational. Fire Clearance was granted 12/12/19. All hazardous items were latched/locked and secured out of reach of children. There are no bodies of water in the home. The pool on the complex premises is gated and locked making it inaccessible to children. Applicant states that there are no weapons in the home. CPR and First Aid expire on 12/31/21. Mandated Reporter certificate exp 03/14/20 and Preventative Health Practices course was taken on 07/2016. 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. Staff immunization requirements were met. Applicant will be using the following rooms for childcare: Living Room, Kitchen, Dining Room, Bathroom #1, and Master Bedroom. Off limits areas include: Bedroom #2, and Bathroom #2 and are inaccessible through the use of doorknob covers and child safety gate. The applicant has sufficient toys and equipment available. The home has a fenced patio available for outdoor activities. Applicant was reminded of requirements for children’s records, child abuse, and unusual incident reporting, immunizations, adults living or working in the home and associated civil penalties, applicant was also reminded that corporal punishment, smoking, walkers, exersaucers, bouncy seats and jumpers are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA provided information regarding Safe Sleep Regulations/SIDS and Shaken Baby Syndrome. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

SUPERVISOR'S NAME: Monica Cuddy	TELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Tyra Block	TELEPHONE: (619) 767-2201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2020

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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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: MOHAMED, SAMSAM FAMILY CHILD CARE	FACILITY NUMBER: 376100222
	VISIT DATE: 01/03/2020

NARRATIVE

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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.

The facility appears to be in substantial compliance. A license for 14 children will be issued after a thorough file review.

The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. LPA provided notice of site visit and observed it being posted at the facility.

SUPERVISOR'S NAME: Monica Cuddy	TELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Tyra Block	TELEPHONE: (619) 767-2201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2020

LIC809 (FAS) - (06/04)

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