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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627064
Report Date: 09/29/2021
Date Signed: 09/29/2021 01:23:15 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: 1DATE:
09/29/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Gholam Gholami and Maryam HoseiniTIME COMPLETED:
01:40 PM
NARRATIVE
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On 9/29/21 at 11:30 AM Licensing Program Analysts (LPAs) Adrian Mangina and Leandra Dolliole conducted a Plan of Correction visit to the child care home to follow-up on deficiency cited during annual continuation inspection on 8/24/21. At arrival, LPA met with Licensees Gholam Gholami and Maryam Hoseini. At 11:40 Licensee Gholam Gholami left the facility. Adult daughter of Licensees, Zahra Gholami, arrived at 11:45 to provide translation services. At 12:45 PM Licensee Maryam Hoseini left to pick up a child to bring them to facility. During the visit, one child arrived at the facility at 12:50 PM after being picked at from home by Licensee Gholam Gholami. There was a total on one child in care. Proper supervision and ratios were observed.

LPAs verified that:

1) Licensee provided complete file for Child #2 and Emergency Consent forms for child #1 and Child #3

LPAs toured the facility and observed that the fountain fence has been changed since last visit such that the slat are now horizonal, not vertical, making the fence climbable. Licensee has install a door to the outside room which serves as one side of the barrier to prevent access to the fountain, but the door ends approximately two feet from the ground, leaving a crawl space which makes the fountain accessible to children.

See LIC809D for deficiency cited during this visit.

Licensee was provided with a copy of this report (LIC809) and Appeal Rights (LIC9058). Their signature on this form is acknowledgement of receipt. A Notice of Site Visit (LIC9213)was also provided and must be posted for 30 consecutive days.
SUPERVISOR'S NAME: Renesha PackTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L ManginaTELEPHONE: (619) 767-2209
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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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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: 09/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2021
Section Cited

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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 LPA observations fence slats are not vertical and fence does not surround fountain becuase door does not etend to ground leavinf a crawl space through which children can access the fountain.
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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: 09/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2021
LIC809 (FAS) - (06/04)
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