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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627064
Report Date: 11/25/2019
Date Signed: 11/25/2019 03:06:55 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: 3DATE:
11/25/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Maryam Hoseini and Gholam GholamiTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Selina Siao conducted an unannounced case management inspection. Upon arrival, LPA met with licensee Maryam Hoseini, her daughter Zahra Gholami who is visiting, adult son residents Hosein Gholami and Fatema Rezaee. Co-licensee Gholam Gholami arrived at the facility from the store during the inspection. Licensee's two minor sons are also at the facility along with two family friends children as day care are not in care during today's inspection.

An updated roster is not available for review today. See LIC809D for citation issued:



Appeal Rights (1/16) were discussed and provided. Signature at the bottom of this report confirms receipt. Notice of Site Visit was posted during this visit and will remain posted for 30 days.


This inspection and licensing report was translated to both licensees by her daughter Zahra Gholami in Farsi during today's inspection.
SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Selina SiaoTELEPHONE: (619) 767-2217
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2019
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: GHOLAMI, GHOLAM & HOSEINI, MARYAM FCC
FACILITY NUMBER: 376627064
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2019
Section Cited

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Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
This requirement was not met as evidenced by:
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An updated roster is not available for review during today's inspection. This poses a potential health and safety risk to clients 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: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Selina SiaoTELEPHONE: (619) 767-2217
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2