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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629255
Report Date: 12/28/2021
Date Signed: 12/28/2021 10:26:45 AM

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:KHAMIS, MARIAM FAMILY CHILD CAREFACILITY NUMBER:
376629255
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
12/28/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Mariam Khamis, Applicant TIME COMPLETED:
10:40 AM
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On 12/28/2021 at 9:35 am, Licensing Program Analyst (LPA) Michelle Hood conducted an unannounced pre-licensing inspection for a change of location with the applicant, Mariam Khamis. The purpose of the inspection is to ensure that the home is in compliance with standards established in CCR, Title 22, Division 12, Chapter 3, for Family Child Care Homes. This 1 story 4-bedroom, 2 bath home was toured and inspected to ensure the environment is safe for the care and supervision of children.

The applicant provided proof of control of the property for review by the Department. The applicant will use the following areas for child care: living room, kitchen, dining room, backyard, bedroom #2 and bathroom #1. Off-limits areas include bedroom #1, bedroom #3, bedroom #4, garage and bathroom #2. They are made inaccessible to daycare children through the use of door locks, and doorknob covers. The applicant will utilize the backyard. The fire extinguisher is rated 2A 10B: C, smoke, and carbon monoxide detectors meet requirements and are operational. All poisons, cleaners, and hazardous items in the home are inaccessible to children through latches, locks, and/or placed up on high surfaces. The applicants mandated reporter training expires on 11/30/2023, and CPR/First Aid expires on 01/19/2022. LPA review the facility roster and children's files.

The applicant does not plan on providing IMS to clients. 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

SUPERVISOR'S NAME: Cynthia GrayTELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Michelle HoodTELEPHONE: (691) 767-2241
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
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 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: KHAMIS, MARIAM FAMILY CHILD CARE
FACILITY NUMBER: 376629255
VISIT DATE: 12/28/2021
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The New Provider Resource Packet was reviewed with the applicant including information on the following: SIDS, shaken baby, insurance, child abuse reporting, community resources, children’s records, facility records, required postings, immunization's, unusual incident report, roster, car seat law, visual for ratio/capacity, and fire/disaster drill log. The applicant was also informed the following items are prohibited during daycare operating hours (walkers, exersaucers, jumpers, and bouncy seats). Corporal punishment and smoking are not allowed in the daycare. LPA discussed the safe sleep regulations with the applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. The applicant understands they must physically check on sleeping infants every 15 minutes. An Individual Infant Sleeping Plan [LIC 9227 (3/20)] will be maintained for each infant up to 12 months of age and shall be available to the Department for review. The applicant understands infants up to 12 months of age must be placed on their backs for sleeping.

The maximum capacity for a small family child care home: 4 infants only (infants mean any children under 24 months); or 6 children with no more than 3 infants; or (with landlord consent) 8 children with no more than 2 infants, 1 child in kindergarten or elementary school and 1 child at least age 6 including children under age 10 who live in the licensee's home. To access our Regulations and Forms please use our WEBSITE: http://ccld.ca.gov.

No corrections needed. A Regular Small Family Child Care Home license may be issued upon final file review. An exit interview was conducted with Mariam Khamis.
SUPERVISOR'S NAME: Cynthia GrayTELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Michelle HoodTELEPHONE: (691) 767-2241
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
LIC809 (FAS) - (06/04)
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