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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627064
Report Date: 09/20/2021
Date Signed: 09/20/2021 12:43:11 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. & GHOLAM G.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 792-8995
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:14CENSUS: 0DATE:
09/20/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Gholami Gholami and Maryam HoseiniTIME COMPLETED:
01:00 PM
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On 9/20/21 at 9:30 AM Licensing Program Analyst (LPA) Adrian Mangina and Licensing Program Manager (LPM) Renesha Pack arrived to conduct an Annual Continuation Inspection to complete the Annual Inspection begun on 9/8/2021. At arrival LPA and LPM met with both Licensees Gholami Ghlam and Maryam Hoseini. Adult son Alireza Gholami was also present in the home and provided translation. During the visit LPA and LPM toured the facility inside and out and reviewed child files. During the inspection, LPA and LPM observed the garage has been converted to a playroom (not used for daycare), 1 bedroom/bathroom. Alterations to the front of the home include a counter area being installed. The entire converted area is not used for daycare and must be made inaccessible. There is a adjacent large family room with master bedroom and additional room which is made inaccessible by high latch. An additional bedroom off hallway which is inaccessible by locked door. Areas used for daycare and are accessible include living room, dining room, kitchen, hallway bathroom, and laundry area. LPA and LPM also inspected backyard, there were hazardous items and a shed built in the backyard which contains food and rugs but no hazardous items. All hazards were removed and placed in a gated off limits area of the back/side yard. LIcensees will use right side of home into kitchen as entry, left side of home to remain off limits The fountain in the front yard has been gated but not fully fenced and is still accessible on the sides as well as through the covered patio area that was built. Licensee states will make it fully inaccessible by extending the fence enclosing the patio area that leads to the large fountain. LPA advised must provide direct visual supervision when outside. Licensees were advised that they need to submit an LIC9052 Criminal Records Clearance Transfer for any one who may be in the home and has access to children in care.

In addition, LPA and LPM conducted a Plan of Correction inspection and verified that the following were corrected:
1) Remove unsafe items including glass, oven and windows from back yard
2) Licensee has Provided complete LIC9040 Child roster
3) UpdatedDisaster drill log to present date was provided. last drill 5/18/21.
SUPERVISOR'S NAME: Renesha PackTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L ManginaTELEPHONE: (619) 767-2209
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: GHOLAMI, GHOLAM & HOSEINI, MARYAM FCC
FACILITY NUMBER: 376627064
VISIT DATE: 09/20/2021
NARRATIVE
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LPA and LPM reviewed files and observed that three three of the files are incomplete and/or missing.

LIcensee was advised to provide LPA with updated LIC9099A pages 1 and 2 (inside and outside) no later than 9/22/2021. LPA provided LIC311D to Licensee.

See LIC809D for deficiencies cited. An exit interview was conducted and Licensee was provided with appeal rights (LIC 9058) along with a copy of this report (LIC 809). Upon receipt of this report, licensee shall post and provide copies of this licensing report to parents /guardian of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. Licensee to provide Acknowledgement of Receipt of Licensing Reports (LIC 9224) to the parent/guardian of for each child in care for signature acknowledging receipt of copy of this report. THIS REPORT MUST BE FILED IN FACILITY FILE AND MADE AVAILABLE FOR PUBLIC REVIEW FOR 3 YEARS.
SUPERVISOR'S NAME: Renesha PackTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L ManginaTELEPHONE: (619) 767-2209
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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, 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: 09/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2021
Section Cited

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(5) All licensees shall ensure the inaccessibility of ... bodies of water...by surrounding the pool with a fence...at least five feet high... In addition to meeting all of the aforementioned requirements for fences, gates shall swing away from the pool, self-close and have a self-latching device... This requirement was not met as evidenced by:
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Based on observation, Although Licensees built a fence, the fence does not fully surround the fountain leaving it accessible to children. LPA provided Section 102417 to Licensees.
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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: Renesha PackTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L ManginaTELEPHONE: (619) 767-2209
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2021
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, 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: 09/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2021
Section Cited

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The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7).
This requirement was not met as evidenced by:
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Based observation and file review, Licensee did not have completed Emergency Consent form for two of three children and did not have a file for one of three children in care which poses a potential health and safety risk to 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: Renesha PackTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L ManginaTELEPHONE: (619) 767-2209
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4