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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198000631
Report Date: 08/05/2026
Date Signed: 08/05/2026 03:47:11 PM

Document Has Been Signed on 08/05/2026 03:47 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:KAKISH, SAMIRA & SAMIR FAMILY DAY CAREFACILITY NUMBER:
198000631
ADMINISTRATOR/
DIRECTOR:		KAKISH, SAMIRA & SAMIRFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 593-9858
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY: 14TOTAL ENROLLED CHILDREN: 1CENSUS: 1DATE:
08/05/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Licensee, Samira KakishTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 08/05/26 at 12:15pm, Licensing Program Analyst (LPA) Diana Ortiz conducted an unannounced annual random inspection to the above facility. LPA was greeted by Licensee, Samira Kakish to whom the reason for the visit was explained. Licensee guided LPA on a tour of the facility. Census was taken and LPA observed one (1) child in care. Per Licensee, there is currently one (1) child enrolled. A current children’s roster was available for review. Hours of operation are from Monday through Friday from 7am-7pm. Facility capacity is in compliance for a Large Family Child Care Home. The licensee was observed to be operating within the license capacity limitations at the time of inspection. LIC 126 Entrance Checklist was provided to Licensee.

LPA observed the following required posted documentation in the main entry way of the facility: Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. LPA reviewed facility records for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan.

This is a single-story home which consists of 3 bedrooms, 2 bathrooms, kitchen, kids room/living room, dining area, second living room, attached garage, and backyard (fenced). Currently residing in the home are two (2) adults and zero (0) minor children. There was a total of two (2) adults present during this inspection. All adults present at time of inspection are fingerprint cleared and associated to facility in Guardian.

Areas accessible to children were inspected as follows: one bathroom (located in the hallway), dining area, kitchen, kids room, and backyard.

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Brandi VanOosten
Diana Ortiz
DATE: 08/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2026
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/05/2026 03:47 PM - It Cannot Be Edited


Created By: Diana Ortiz On 08/05/2026 at 12:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: KAKISH, SAMIRA & SAMIR FAMILY DAY CARE
FACILITY NUMBER: 198000631

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in both licensee and licensees assistant had expired mandadted reporter with expiration date of 11/2025 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2026
Plan of Correction
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Per licensee, she will take the AB1207 mandated reporter training and provide LPA with proof of completion by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Brandi VanOosten
NAME OF LICENSING PROGRAM MANAGER:
Diana Ortiz
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2026


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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KAKISH, SAMIRA & SAMIR FAMILY DAY CARE
FACILITY NUMBER: 198000631
VISIT DATE: 08/05/2026
NARRATIVE
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Per licensee, the areas that are inaccessible to children include: bedrooms, bathroom, and attached garage. LPA observed that doors are kept closed and locked. During this visit, all areas identified on the facility sketch that are accessible for children to use were toured and inspected.

Tour began in the kids room/living room which is the main daycare room. LPA observed age-appropriate toys, equipment, and materials available for the children. LPA observed that the children's bathroom was safe, clean, and sanitary. All areas identified on the facility sketch as accessible to children were inspected and found to be clean, orderly, and equipped with adequate ventilation and heating to ensure the safety and comfort of the children. Telephone service is available through cellular phone and landline. LPA observed age-appropriate toys that were in good condition and free of loose or sharp parts. Licensee stated that there are no poisons stored in the home and acknowledged the requirement that any poisonous substances must be kept locked and inaccessible to children. Licensee was advised that the accessibility of potential hazards must be continually reassessed based on the ages and developmental abilities of the children in care.

The licensee uses the backyard as the outdoor activity area for children. LPA observed that the outdoor play area is enclosed by a cement wall along its perimeter. Age-appropriate toys and play materials including play structures were available, and no hazardous objects or conditions that could pose a risk to children were observed. According to the licensee, children are supervised at all times while outdoors.

Licensee states that she is not part of a food program. Per licensee, she provides breakfast, lunch, am/pm snacks for the children in care. LPA advised that if parents do provide food, that it must be labeled with child’s name and stored appropriately. Per Licensee, there is central air and heating in the home. Licensee states there are no pets in the home and LPA did not observe any pets at the time of inspection.

Per Licensee, the ill/isolation area is in the room located in the living room. The children will wait on the sofa for parents or authorized representatives to pick them up.

Detergents, cleaning compounds, and medications were observed to be inaccessible to children. Per Licensee, there are no weapons or firearms or bodies of water in the home or in the premises. LPA did not observe any weapons or firearms or bodies of water in the premises at time of inspection.

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NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Diana Ortiz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2026
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KAKISH, SAMIRA & SAMIR FAMILY DAY CARE
FACILITY NUMBER: 198000631
VISIT DATE: 08/05/2026
NARRATIVE
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The valve on the required 2A 10BC fire extinguisher indicates fully charged. Last fire and disaster drill was conducted on 05/25/2026. Reminded Licensee that all homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill. Licensing staff observed a fireplace located in the living room next to the kitchen barricaded by a metal gate.

The home is observed to be clean and orderly. There are first aid supplies available located in the main daycare area near the entrance. LPA observed that there are age-appropriate toys available for children. Appropriate sleeping arrangements in form of mats were observed.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization's Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, and LIC 995A Notification of Parents’ Rights.

Staff files were reviewed for the following: LIC 508- Criminal Record Statement, Proof of immunizations against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse.

Pediatric First Aid and CPR certification expires on 07/2027 for Licensee and licensees assistant. Mandated Reporter Training for expired on 11/2025 for licensee and for assistant. This poses a potential health and safety risk to children in care. Reminded licensee that AB 1207, mandated reporter training, should be conducted every two years.

AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers.

Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

LPA did not observe the following items during the inspection: Johnny Jumpers, Saucer Chairs, and/or any other item that fall into these categories are not permitted in a family childcare facility.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home.


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NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Diana Ortiz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2026
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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KAKISH, SAMIRA & SAMIR FAMILY DAY CARE
FACILITY NUMBER: 198000631
VISIT DATE: 08/05/2026
NARRATIVE
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A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Based on Licensing staff observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health and safety.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Samira Kakish.

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NAME OF LICENSING PROGRAM MANAGER: Brandi VanOosten
NAME OF LICENSING PROGRAM ANALYST: Diana Ortiz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2026
LIC809 (FAS) - (06/04)
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