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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603481
Report Date: 12/11/2024
Date Signed: 12/12/2024 09:49:16 AM

Document Has Been Signed on 12/12/2024 09:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MARYAM ARFFACILITY NUMBER:
374603481
ADMINISTRATOR/
DIRECTOR:		LEEDA DOSTFACILITY TYPE:
735
ADDRESS:9319 NORTHVIEW TERRACETELEPHONE:
(858) 348-7247
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY: 6CENSUS: 5DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Licensee Leeda DostTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced annual inspection on December 11, 2024. LPA Correia met with Licensee Dost, identified herself, was granted entrance into the facility, and explained the purpose of the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) clients, two (2) of whom may be non- ambulatory. During today's visit there were no clients in care at the facility, and two staff members.

LPA Correia, accompanied by Licensee Dost, toured the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal and hot water temperature were with-in Licensing guidelines.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, open-faced heaters or fireplaces accessible to clients. Medications were labeled, as required, and stored in locked areas.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MARYAM ARF
FACILITY NUMBER: 374603481
VISIT DATE: 12/11/2024
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No pools or bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. The facility does have a physical telephone. Fire extinguishers were in compliance. First aid kit was complete and readily accessible. Licensee Dost had current Administration Certification and liability insurance.

LPA Correia reviewed multiple staff and client records/files that were observed to be complete and accurate. Client's P&I was accurate and complete.

An exit interview was conducted with Licensee Dost to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) will be provided at the conclusion of the visit.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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