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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 376100575
Report Date: 11/19/2021
Date Signed: 11/19/2021 11:47:46 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/02/2021 and conducted by Evaluator Tyra Block
PUBLIC
COMPLAINT CONTROL NUMBER: 51-CC-20210902120422
FACILITY NAME:KHALIF, SAMSAM FAMILY CHILD CAREFACILITY NUMBER:
376100575
ADMINISTRATOR:SAMSAM KHALIFFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 228-3835
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY:14CENSUS: 1DATE:
11/19/2021
UNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Nimo HassanTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Facility is operating over capacity.
INVESTIGATION FINDINGS:
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On 11/19/21, Licensing Program Analyst (LPA), Tyra Block made an unannounced complaint visit for the purpose of delivering findings on the above referenced allegation received 9/2/21. LPA met with helper Nimo.

Based on the information obtained during interviews with licensee, parents, and staff, observations, and documentation reviewed it is determined that on multiple dates in the month of June licensee was over capacity during the afternoon hours.
The allegation is valid because the preponderance of the evidence has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 12, Chapter 1) the Type B deficiency is being cited on the attached LIC 9099D.

The Notice of Site Visit was provided, and LPA observed posting. Licensee is advised it must remain posted for 30 days. An exit interview was conducted, a copy of this report and Appeal Rights (1/16) were discussed and provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Tyra Block
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 51-CC-20210902120422
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: KHALIF, SAMSAM FAMILY CHILD CARE
FACILITY NUMBER: 376100575
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2021
Section Cited
CCR
102416.5(a)
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102416.5(a) Staffing Ratio and Capacity: The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. The requirement was not met as evidenced by:
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Provider has began keeping attendance sheets in the home and maintains schedule for each child nearby. Provider will ensure no more than licensed capacity of 14 children are cared for at one time and will mark time on attendance sheets rather that have parents do it. Provider will email plan of correction by 11/26/21.
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Based on inteveiws, observation, and documentation reviewed licensee has documented and cared for more than 14 children on more than 1 occasion in the month of June. This posed a potential health and safety risk to children in care.
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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.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Tyra Block
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2