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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627064
Report Date: 09/08/2021
Date Signed: 09/08/2021 12:17:28 PM


Document Has Been Signed on 09/08/2021 12:17 PM - It Cannot Be Edited

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:
09/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Gholami Gholami and Maryam HoseiniTIME COMPLETED:
12:30 PM
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On 9/8/21 at 8:30 AM, Licensing Program Analyst (LPA) Adrian Mangina conducted an unannounced Annual inspection with the Licensee. Upon arrival, LPA met with Licensees, Maryam Hoseini and Gholami Gholami. The one-story four bedroom three bathroom home was toured and inspected to ensure an environment safe for the care and supervision of children. Also present in the home was adult daughter Zahra Gholami who provided translation until 9:44 AM when LPA called language link and interpreter #13224 Yeganeh, began translation Also in the home were licensee’s own two minor children. Adult daughter Zahra Gholami returned to the facility at 9:58 AM to resume translation. There were no children in care during the visit. Proper supervision and ratios were observed. The 2A10BC fire extinguisher located in off limits playroom, the carbon monoxide detector located in the dining area and smoke detector located in the living room meet requirements and are operational. LPA observed that Licensees have finished part of the garage into living space, including a playroom and kitchen living/room. Licensees also removed a closet and built a kitchen and living room in what used to be the front bedroom. Licensees also built an outdoor room and installed a two and a half foot deep concrete pond/water feature. LPA observed a grill and rusty items in the unfenced front yard which leads to the home’s entrance. The former front door is no longer used for children as it has been converted into a separate living space for Licensee’s son, Alireza Gholami. LPA observed that the backyard is accessible to children and contains several unlocked sheds that store gardening supplies, tools and other dangerous items. Licensee also observed windows leaning against a fence. Licensee stated that children do not go into back yard, though it is listed as play space for the children on the facility map. Licensee was reminded that in order to make the backyard off limits it needs to be made inaccessible to children through the use of latches, locks or gates. Licensees advised that they must report within 10 days any changes to the physical space inside and outside the home. Licensee was advised to remove the dangerous items in the front and back yards to off limits areas. Licensee advised that they must cover the pool such that a child will not fall in and to make the unpermitted outdoor structure inaccessible to children as it is elevated and has no

(continued on LIC809 page 2)
SUPERVISOR'S NAME: Renesha PackTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L ManginaTELEPHONE: (619) 767-2209
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2021
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 5


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: 09/08/2021
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(LIC809 page 2)

walls. Licensee Gholami stated that all the construction occurred in the past one to two years. Licensee states that he did not inform Licensing of the work being done. Licensees say they do not have a roster available for LPA to review. Licensee states that the work was permitted but they could not produce the permits. Licensee Gholami states that the newly created “playroom” is not used for children, but the space was not made inaccessible to children. LPA reminded Licensees that the according to fire clearance, the former garage area, now called playroom, cannot be used for the child care. Licensee will review with manager whether a new fire clearance is needed. LPA reminded that all off limits rooms must be made off limits through the use of latches, locks or gates. LPA observed that the big living room was left unlocked which made that room and two bedrooms and a bathroom accessible to children. Licensee locked the door while LPA was present. LPA observed chemicals under kitchen sink and a previously unreported laundry room off kitchen that had soaps and detergents on an open shelf which were removed while LPA was present. Licensee reminded that all items marked “keep out of reach of children” must be kept in inaccessible areas of the home. Licensee states that there are no weapons in the home. 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. Licensee Maryam’s First Aid and CPR certifications expire on June 30, 2022. Licensee Gholami’s First Aid and CPR certifications expire on April 30, 2023. Mandated Reporter Training was waived due to both Licensee’s first languages are not English. Licensee states that her last disaster drill was five months ago, but the Emergency Disaster drill log shows last disaster drill was 11/31/2019. Licensee reminded to conduct disaster drills every six months. Licensee has provided adequate space for the children to eat, sleep and play within the home. Areas used for child care include: living room, kitchen, dining area and bathroom #1. Off limits areas include: Big Living, Bedroom #1, bedroom #2, bedroom#3, bedroom#4, second kitchen, second living room, bathroom #2, bathroom #3 and are inaccessible through use of door locks and latches. There is There is a working phone at the facility. The licensee has sufficient safe age appropriate, toys and equipment available. Licensee now utilizes a neighborhood park for outdoor activities. LPA observed that Licensee did not have all required postings. LPA provided Licensees with a list of required postings.


(continued on LIC809 page 3)
SUPERVISOR'S NAME: Renesha PackTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L ManginaTELEPHONE: (619) 767-2209
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: 09/08/2021
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Provider is hereby reminded of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, ensure that all adults living or working in the home have criminal background clearances associated to the facility, corporal punishment, smoking, exersaucers,
bouncy seats, walkers, and jumpers are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov. LPA Mangina reviewed Covid-19 guidelines with Licensee and provided Covid-19 resources. LPA Mangina directed Licensee to website: https://www.cdss.ca.gov/inforesources/community-care-licensing to receive important updates and information.

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.

See LIC 809D for Deficiency(s) cited during visit.

An exit interview was conducted with the Licensee. The Licensee was provided a copy of their 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. Annual visit will have to be continued at a later time. Licensee were upset that LPA was giving citation and refused to sign the report.
SUPERVISOR'S NAME: Renesha PackTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Adrian L ManginaTELEPHONE: (619) 767-2209
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/08/2021 12:17 PM - It Cannot Be Edited

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: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2021
Section Cited

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Alterations to Existing Buildings or Grounds: Prior to making alterations or additions…the licensee shall notify the Department of the proposed change…conversion of a garage… installation of in-ground or above-ground swimming pools, spas, fish ponds, decorative water feature, fountains or other bodies of water.
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This requirement was not met as evidenced by: Licensee converted a garage into a playroom and kitchen/livingroom, installed a concrete pond and installed a laundry room Licensee states this construction occurred in past one or two years which is an immediate health and saftey risk to children in care.
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Request Denied
Type A
09/09/2021
Section Cited

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Operation of a family child care home: The home shall be free from defects or conditions which might endanger a child.
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THis requirement was not met as evidenced by: Licensee's back yard has open/unlocked shed that contains a case of matches and there are windows propped against the fence and several broken stoves on the ground and on a table which poses an immediate health and safety risk to children in care.
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Licensee will remove items or make the area inaccessible no later than close of business 9/9/21.
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: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 09/08/2021 12:17 PM - It Cannot Be Edited

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: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
09/22/2021
Section Cited

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Operation of a family child care home: Each family child care home shall conduct
fire drills and disaster drills at least once every six months…The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home.

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Type B
09/22/2021
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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THis requirement was not met as evidecend by:Licensee was unable to provide LPA with a current roster.
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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: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2021
LIC809 (FAS) - (06/04)
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