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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 376100575
Report Date: 12/01/2022
Date Signed: 12/01/2022 04:56:17 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
09/27/2022 and conducted by Evaluator Tyra Block
PUBLIC
COMPLAINT CONTROL NUMBER: 51-CC-20220927141320
FACILITY NAME:KHALIF, SAMSAM FAMILY CHILD CAREFACILITY NUMBER:
376100575
ADMINISTRATOR:SAMSAM KHALIFFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 228-3835
CITY:SAN DIEGOSTATE: ZIP CODE:
92119
CAPACITY:14CENSUS: DATE:
12/01/2022
UNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Samsam KhalifTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Child in care inappropriately disciplined
Conduct Inimical
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/1/22, Licensing Program Analysts ( LPAs), Tyra Block and Saraliz Velando, made an unannounced complaint visit for the complaint received on 9/27/22 for the purpose of delivering findings on the above referenced allegations. Present with licensee were 7 children with helpers Nimo, Mukhtar, and Anab. Over the course of the investigation, LPA Block conducted interviews and record review and determined the allegations are UNSUBSTANTIATED.
Based on interviews and records obtained, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A concurrent investigation was conducted by Child Welfare Services as licensee also has a foster license and it was determined that there was no evidence to support the allegation a child was inappropriately disciplined., therefore, conduct inimical is also unsubstantiated. No deficiencies were cited during today's visit.
An exit interview was conducted with licensee, Samsam Khalif. 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: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
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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