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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 376100575
Report Date: 11/08/2022
Date Signed: 11/08/2022 05:35:34 PM

Unsubstantiated


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
11/03/2022 and conducted by Evaluator Tyra Block
PUBLIC
COMPLAINT CONTROL NUMBER: 51-CC-20221103154437
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: 10DATE:
11/08/2022
UNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Samsam Khalif and Nimo HassanTIME COMPLETED:
05:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Day care child left in soiled diaper for extended period of time
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/8/22, LPA, Tyra Block, made an unannounced initial 10-day visit, for the complaint received on 11/3/22. regarding the above allegation. LPA met with licensee, Samsam Khalif and assistant, Nimo Hassan. Also present in the home were 10 daycare children and helper, Anab Elmi. LPA conducted interviews with children and staff, and received a copy of the children’s roster.
It was alleged a day care child was left in a soiled diaper for an extended period of time. Based on the information obtained during interviews and observations it is determined that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The above allegation was found to be UNSUBSTANTIATED. LPA discussed with licensee and helpers diapering routines and they stated children requiring diapering are changed every 1-2 hours or more if needed and diapers are provided by parents daily.Licensee also keeps back up diapers. LPA also observed a changing table available for diapering. An exit interview was conducted with Samsam and a Notice of Site Visit was provided and must be posted for 30 days.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Tyra Block
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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