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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495066
Report Date: 05/03/2022
Date Signed: 05/03/2022 03:11:12 PM

Document Has Been Signed on 05/03/2022 03:11 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:EBRAHIM FAMILY CHILD CAREFACILITY NUMBER:
197495066
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
05/03/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Marsel EbrahimTIME COMPLETED:
03:23 PM
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Licensing Program Analyst (LPA), Keyona Scott, conducted an announced Pre-licensing inspection on 05/03/2022. LPA met with Applicant, Marsel Ebrahim, at 10:48 AM and was guided on a tour inside and outside of the home.

Present during today’s inspection was Applicant and Applicant’s spouse. Adults residing in the home include Applicant and Applicant’s spouse. All Adults present, residing, working and/or volunteering in the home have a criminal record clearance or exemption. The LIC279B (Children In Your Home) is on file at the El Segundo Child Care Regional Office.

Applicant has applied to provide care for children ages one (1) day to six (6) years of age. Upon licensure, Applicant will be granted the capacity to care for up to eight (8) children at a time; four infants only or six children with no more than three infants or eight children with no more than two infants and two school age children age six years old or older and one currently attending Kindergarten. Child Care operation hours are scheduled for Monday through Friday, 6:30 AM to 6:00 PM. Per Applicant, children will be provided three meals (breakfast, lunch and dinner) and two snacks while in care. LPA advised Applicant, if meals and/or snacks are brought from the child(ren)’s home, the container(s) shall be labeled with child(ren)’s name and properly stored or refrigerated.

All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a one-story home that consists of three bedrooms, three bathrooms, living room, dining room, office, kitchen, laundry room and attached garage. Per Applicant, childcare activities will be conducted in the attached garage. Applicant is aware that no eating or napping can be conducted in the attached garage. Off limit areas of the home are the three bedrooms and the master bathroom located in the master bedroom. The three bedrooms and master bathroom are made inaccessible by closed doors during operation hours. Applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary. Page 1

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2022
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 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: EBRAHIM FAMILY CHILD CARE
FACILITY NUMBER: 197495066
VISIT DATE: 05/03/2022
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Per Applicant, childcare will be conducted in the attached garage located to the west of the front entrance of the home. Parents will drop off and pick up child(ren) at the front door entrance of the home. Health checks will be conducted daily at the front entrance prior to parents leaving and the child(ren) entering the home. LPA observed the following age-appropriate toys in the childcare area: couches, cubby storage for toys, legos, play cars, crayons, riding rockers and other age appropriate toys. Child(ren) in care will utilize the office located at the rear of the home adjacent to the kitchen, for napping. LPA observed napping mats and cots stored in the home. The dining room located adjacent to the front entrance will be utilized for meal and snack time and also as an isolation area for child(ren) that become ill during care. Children in care will utilize the bathroom directly through the hallway entrance adjacent to the living room. Per Applicant, children in care will be escorted to the bathroom as needed. LPA did not observe any cabinets or drawers in the bathroom. Children will utilize the living room, located at the front entrance of the home as an area for teaching, exercising and entertainment. Per Applicant, there is no fireplace in the home; none was observed by LPA. The bathroom door for the bathroom located to the west of the kitchen will remain closed during operation hours. The laundry room is located outside to the west of the home. Per Applicant, the laundry room door will remain closed and locked during operation hours.

The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Home has a working telephone. Hazardous materials in the kitchen and bathroom are inaccessible to children. All poisons are locked. The home utilizes centralized heat and air system as a heating and cooling source. Per Applicant, there are no weapons or firearms in the home; none were observed by LPA. Per Applicant, there is a pet dog in the home; which will remain inaccessible to child(ren) during operation hours.

The home is equipped with at least one fully charged fire extinguisher which is at least a 2A:10:BC. The home is equipped with at least one working smoke and carbon monoxide detectors. There is at least one first aid kit in the home. LPA received and reviewed current Pediatric CPR and First Aid certificates for Applicant with expiration date of 02/09/2024. Mandated Reporter training was completed on 02/24/2022. Applicant completed Preventative Health and Safety training with one hour of Childhood Nutrition and Lead Exposure prevention on 02/20/2022. Family Child Care Home Orientation was completed by Applicant on 01/28/2022 and a copy of the certificate was provided to the Department.

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SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC809 (FAS) - (06/04)
Page: 10 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: EBRAHIM FAMILY CHILD CARE
FACILITY NUMBER: 197495066
VISIT DATE: 05/03/2022
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Outdoor play will be in the backyard of the home. Children will enter the outdoor play area through the kitchen located at the rear of the home. The outdoor play area is fully fenced. LPA observed peeling wooden board covering the crawl spaces to the east and west of the home need to be replaced. Applicant agrees to replace wooden boards that are covering crawl space areas on both sides of the home. Applicant states will send pictures and video of the corrections once completed. LPA also observed there is an open space between the wall and the east and south of the storage shed. Applicant agrees to place a boundary on each side of the storage shed to make the space between the wall and shed inaccessible to child(ren) in care. Applicant will send pictures of corrections once completed. Per Applicant, the storage shed will not be used for childcare purposes and the storage shed door will remain closed and locked during operation hours. LPA observed age-appropriate push car and scooter in the outdoor play area. Applicant agrees to purchase additional age appropriate toys for outdoor play area prior to having children attend childcare. No pools, spas, hot tubs, fishponds, or similar bodies of waters observed on home premise. Applicant was advised that children shall always be physically and visually supervised.

Per Applicant, transportation service will not be provided.

While touring the home LPA observed the following required form posted:

· Notification of Parent’s Rights (PUB 394)



Applicant has submitted Emergency Disaster Plan to the Department and has on file in the home for review upon request.

Applicant has completed Earthquake Preparedness Checklist (LIC 9148) and placed on file in the home for review upon request.


Page 3
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC809 (FAS) - (06/04)
Page: 3 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: EBRAHIM FAMILY CHILD CARE
FACILITY NUMBER: 197495066
VISIT DATE: 05/03/2022
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Applicant was informed that it is required by law to post the following in the facility:
● Emergency Disaster Plan (LIC 610A) - This must be posted in your home next to the telephone and the Earthquake Preparedness Checklist (LIC 9148), must be attached to the LIC 610A and available to the public.
● Notification of Parents' Rights Poster (PUB 394) - This poster must be placed in an area of the home where all parents can see it
● Facility License, (LIC 203)-Your Family Child Care Home License must be posted in an area of the home where it can be easily seen.
● Notice of Site Visit (LIC 9213) must remain posted for 30 days (during the hours that children are in care) after each site visit by a licensing representative.
● Any licensing report documenting a type “A” citation must be posted for 30 days during the hours that children are in care.
● Any licensing report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

Employee records must be maintained by the applicant and shall contain the following:
LIC9052/Employee Rights, LIC 9108 Mandated Reporter Form, an employment contract or application containing the following information: Employees Full Name, Date of Birth, Driver's License Number, Date of Employment, Documentation of Health and Safety Training, Duties of the employee. Licensee is reminded that records for employees as well as children must be maintained for 3 years after separation from the Family Child Care Home (FCCH).

Mandatory Forms for the Children’s files shall contain the following: LIC 282 Affidavit Liability Insurance, LIC 627/Consent for Medical Treatment, LIC 700/ID and Emergency Information, LIC 995A/Parent's Rights, LIC995E/Caregiver Background Check, LIC 9150/Parent Notification, LIC 9212/Parent's Responsibilities, PM 286/Immunization (Blue) Card.

Applicant also informed children records, and facility roster must be kept for 3 years and advised all public reports must be kept for review. Forms and Regulations available at: www.ccld.ca.gov.


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SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC809 (FAS) - (06/04)
Page: 9 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: EBRAHIM FAMILY CHILD CARE
FACILITY NUMBER: 197495066
VISIT DATE: 05/03/2022
NARRATIVE
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The following was thoroughly discussed with the Applicant:

Applicant was reminded, upon licensure it is the licensee’s responsibility to know the regulations as well as anyone who assists in providing care. Applicant was advised on how to access quarterly reports, forms, and regulations for Child Care online at www.ccld.ca.gov. Applicant was also encouraged to read the Child Care quarterly updates every season as the come out to stay informed of any changes or updates to the regulations.

All adults living and working in the home must be fingerprinted and cleared prior to entering the facility. The Applicant was informed that the presence of adults in the home without Criminal Record Clearance or Exemption will be cited and civil penalty assessed for $100 per day. The Applicant may find additional information and forms on the DSS website at www.ccld.ca.gov including information on the Live Scan application (LIC 9163). Appointments can be made for Live Scan at 1-800-315-4507.
After licensure, Licensee can be cited a civil penalty of $100 per day, up to $500.00 for the 1st offense and up to $3000.00 for the 2nd offense within a 12-month period, PER PERSON.
Upon a finding of noncompliance with a plan of correction for violations of Sections 102419(a)(8), (b), (c), (d), (d)(1), or (d)(2), the Department shall impose a civil penalty of fifty dollars ($50) per day until the deficiency is corrected. Subsequent violations of any provision of these sections within 12 months of the initial citation will result in a civil penalty of $150 plus an assessment of $50 per day until the deficiency is corrected.

Applicant was made aware of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on childcare licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541
Email Address: childcareadvocatesprogram@dss.ca.gov

Senate Bill 792: Commencing September 1, 2016, SB 792, prohibits a person from being employed or volunteering at a childcare facility or family day care if he or she has not been immunized against influenza, pertussis and measles. LPA discussed the influenza waiver during the inspection. Page 5

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC809 (FAS) - (06/04)
Page: 7 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: EBRAHIM FAMILY CHILD CARE
FACILITY NUMBER: 197495066
VISIT DATE: 05/03/2022
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New Immunization Requirement: Law enacted by SB 277, beginning January 1, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into childcare or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint.

***CCC - Nutrition Requirement: Beginning January 1, 2016, AB 290 will require for each new license issued, at least one director or teacher at each childcare center or family childcare home to have at least one hour of training in the importance of childhood nutrition. This applies to anyone submitting a new application, relocating their facility, selling their facility or transferring their license. Please note this training cannot be completed online or by home study programs. The training must be taken from an Emergency Medical Services Authority (EMSA) approved training program OR an accredited college or university.

Mandated Reporter: Beginning on January 1, 2018, AB 1207, requires all licensed providers, applicants, directors and employees to complete General and Child Care Mandated Reporter training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/.

The Applicant was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot line at 1-800-540-4000. Also call the CCL office within 24hours of the Unusual Incident and follow up with a written Unusual Incident/Injury Report (LIC 624B) within 7 business days.



Applicant informed Fire disaster drills are to be conducted at least once every six month and log must be kept.

Applicant was advised that regulation prohibits the smoking of tobacco in a private residence licensed as a family childcare home during the hours of operation.

Applicant was made aware that state law prohibits baby walkers, bouncy seats, seersuckers and any other items that fall into that category.

Applicant was also reminded that only children eating may be in highchairs and that car seats are utilized only for transportation. Page 6

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: EBRAHIM FAMILY CHILD CARE
FACILITY NUMBER: 197495066
VISIT DATE: 05/03/2022
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The applicant was advised that, once licensed, the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, (Type A violation), a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed.

LPA discussed AB633 and informed licensee that, upon receipt of a Type A deficiency, the licensee shall post and provide copies of this licensing report to parent/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. Applicant was advised that each parent or child representative must sign the LIC 9224 Acknowledgement of Receipt of Licensing Report and return by the close of the business day or upon the next day the child returns to the facility or upon a newly enrolled child within the next 12 months and place the LIC 9224 in each child's file.

The following was discussed with the Applicant:
· Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Civil Penalties will be assessed if not in compliance.
· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR training, Immunizations (TDAP, MMR, Influenza), mandated reporter training and a valid criminal record clearance associated to the facility license.
· Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
· The fire extinguisher type 2A:10:BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
· Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
· Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.
· Fire and safety drills must be performed every six months and documented for review by the Department. Page 7
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC809 (FAS) - (06/04)
Page: 6 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: EBRAHIM FAMILY CHILD CARE
FACILITY NUMBER: 197495066
VISIT DATE: 05/03/2022
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· Smoking is prohibited in a family childcare home.
· Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
· No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.
· Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
· The facility license number must be on all advertisements, publications or announcements with the intent to attract clients.
· Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).
· Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for details.

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

LPA also discussed Section 10 of the Application for a Family Child Care Home License that the applicant has signed which states the following:


A. I/We live in the home to be licensed.
B. I/We have money to maintain the level of service required by law in a Family Child Care Home.
C. I/We have both State Fire Marshal approved fire extinguisher (rated 2A:10:BC) and smoke detector in operating condition.
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SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC809 (FAS) - (06/04)
Page: 8 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: EBRAHIM FAMILY CHILD CARE
FACILITY NUMBER: 197495066
VISIT DATE: 05/03/2022
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D. I/We shall stay current and in compliance with the law and regulations governing standards for Family Child Care Homes.
E. I/We shall obtain approval from the licensing agency before making changes in our license capacity or to our home.
F. I/We shall notify the licensing agency when we want to discontinue our license.
G. I/We have informed the property owner, if leased or rented, that we will be operating a Family Child Care Home on the premises. The owner/landlord has been sent the Property Owner/Landlord Notification (LIC 9151).
H. I/We have written consent from the property owner, if leased or rented, when I plan to expand my Small Family Child Care Home capacity from 6 to 8 children, or to expand my Large Family Child Care Home capacity to 12 to 14 children. Property Owner/Landlord Consent Form (LIC 9149) has been signed.
I. I/We understand the requirements to report known or suspected child abuse (LIC 9108).

The applicant’s signature on this report acknowledges that they have signed the Application for a Family Child Care Home License (LIC 279) under the penalty of perjury that the statements on the application and any attachments are correct.

Applicant was provided the following forms/brochures via email:
PUB 394: Notification of Parents' Rights Poster
LIC 311D: Forms/Records To Keep In Your Family Child Care Home
Copies of All Required Forms/Records for Children and Personnel Listed on the LIC 311D
Effects of Lead Exposure Pamphlet & Effects of Lead Exposure Parent/Representative Signature Form

New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment

At this time, the facility is not ready for a licensure. Based on the LPA’s observation, corrections are needed prior to licensure. The following must be completed within 30 days, no later than 06/03/2022, or the application can be denied:
  1. Replace peeling wooden board covering crawl spaces on east and west side of home.
  2. Place boundary to prevent access to open space between wall and storage shed to the east and south of storage shed. Page 9
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC809 (FAS) - (06/04)
Page: 5 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: EBRAHIM FAMILY CHILD CARE
FACILITY NUMBER: 197495066
VISIT DATE: 05/03/2022
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Upon completion of the above referenced corrections, the Department will agree to the licensure of a small family childcare for up to eight (8) children at a time. MAX. CAPACITY 8 - four infants only or six children with no more than three infants or eight children with no more than two infants and two school age children age six years old or older and one currently attending Kindergarten. Once licensed, the applicant is required to comply with the terms and limitations stated on the license.

Exit interview conducted and a copy of this report was given to the Applicant, Marsel Ebrahim, whose signature confirms today’s Pre-licensing inspection and report.




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SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Keyona Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC809 (FAS) - (06/04)
Page: 4 of 10