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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627064
Report Date: 09/20/2019
Date Signed: 09/20/2019 12:22:59 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:GHOLAMI, GHOLAM & HOSEINI, MARYAM FCCFACILITY NUMBER:
376627064
ADMINISTRATOR:MARYAM H,& GHOLAMI GHOLAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 792-8995
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:14CENSUS: 5DATE:
09/20/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Maryam HoseiniTIME COMPLETED:
12:30 PM
NARRATIVE
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On 09/20/19 at 11:15 a.m. Licensing Program Analyst (LPA) Brooke Sykora made an unannounced collateral visit to the home. There were five children present with the Licensee, Maryam Hoseini, one of which was under the age of two. The facility is within ratio and capacity. Also present in the home was the Licensee's daughter in law, Fatema Rezaee. The Licensee indicated that her daughter in law resides in the home; however, they have been unable to have her fingerprinted due to delays in obtaining a valid California identification card. A Type A citation will be issued today and a civil penalty of $500 will be assessed. LPA discussed with the Licensee that adults who are present in the home must be fingerprint cleared and associated to the facility before living or working in the home.

An exit interview was conducted. A copy of this report along with LIC809-D and appeal rights (LIC 9058) were provided. Licensee’s signature on this form acknowledges receipt of these rights. 

Upon receipt of a Type A violation, Licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit.

NOTICE OF SITE VISIT WAS POSTED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Jason GarayTELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Brooke SykoraTELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2019
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: GHOLAMI, GHOLAM & HOSEINI, MARYAM FCC
FACILITY NUMBER: 376627064
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2019
Section Cited

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working...in a licensed facility: (1) Obtain a California clearance...as required by the Department. This requirement was not met as evidenced by:
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Based on observation, interview, and record review the Licensee failed to ensure that the adult household member had obtained a criminal record clearance prior to working in the facility which poses an immediate risk to the 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: Jason GarayTELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Brooke SykoraTELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2019
LIC809 (FAS) - (06/04)
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