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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 376100575
Report Date: 06/09/2022
Date Signed: 06/09/2022 01:20:59 PM

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
05/26/2022 and conducted by Evaluator Tyra Block
PUBLIC
COMPLAINT CONTROL NUMBER: 51-CC-20220526160246
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: 2DATE:
06/09/2022
UNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:NImo HassanTIME COMPLETED:
01:26 PM
ALLEGATION(S):
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Licensee was absent from the home for an extensive period of time
INVESTIGATION FINDINGS:
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On (date & time) LPA (Name) made an unannounced complaint visit for the complaint received on 5/26/22 for the purpose of delivering findings on the above referenced allegation.

Based on the information obtained during interviews, observations, and documentation reviewed it is determined that licensee has had excessive absences and has not maintained the required time to be present in the home, therefore, the allegation is found to be SUBSTANTIATED. The allegation is valid because the preponderance of the evidence has been met.
California Code of Regulations, (Title 22, Division 12, Article 6, Chapter 1), the deficiency is being cited on the attached LIC 9099D. The Notice of Site Visit was provided and LPA advised it must be posted for 30 days. An exit interview was conducted with *****
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Tyra Block
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
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-20220526160246
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: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited
CCR
102417(a)
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102417(a)-Operation of a Family Child Care Home: The licensee shall be present in the home and shall ensure that children in care are supervised at all times... Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. This requirement was not met as evidenced by:
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For upcoming trip planned Licensee will go inactive for the duration of the trip and inform parents to make altrnative arrangements. LPA provided LIC 9211- Request for Inactive form to be completed prior to trip. Licensee stated she will discuss with parents to determine dates for inactive.
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 Based on observation, interviews, and documentation reviewed licensee has exceeded the time allowed for absences. Licensee has taken several trips and has not been at the home when licensing has made unannounced visits on multiple occasions. This poses a potential health, safety, and personal rights 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: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2