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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100575
Report Date: 11/19/2021
Date Signed: 11/19/2021 03:24:47 PM

Document Has Been Signed on 11/19/2021 03:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
376100575
ADMINISTRATOR:SAMSAM KHALIFFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 228-3835
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Nimo HassanTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Tyra Block conducted an unannounced annual inspection. The single story home was toured and inspected to ensure an environment safe for the care and supervision of children. Present were helpers Nimo Hassan, Sarah Windham, and Khalid Hassan, and later licensee arrived. Three day care children were present. The fire extinguisher (2A10BC), smoke detector, and carbon monoxide detector meet requirements and are operational. All hazardous items were latched/locked and secured out of reach of children. There are no bodies of water on the property. Helper stated there are no weapons in the home. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. First Aid and CPR certifications expire on 5/2023. Licensee has required immunizations and has completed Mandated Reporter Training. Children’s records were reviewed and found to be incomplete

Licensee has provided adequate space for the children to eat, sleep and play within the home. Areas used for child care include Living Room,Family Room, Bedroom #2, and Bathrooms #1 and #2. Off limits areas include rooms to the left of the home (Master Bedroom and Den), Bedroom #3, Garage/ Laundry Room and Kitchen and are inaccessible through use of door knob covers and door lock. The licensee has sufficient toys and equipment available. The home has a fenced backyard available for outdoor activities.

Provider is hereby reminded of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, follow COVID guidance; corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at (continued on 809-C)
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2021 03:24 PM - It Cannot Be Edited


Created By: Tyra Block On 11/19/2021 at 02:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 4 files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2021
Plan of Correction
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Licensee/ Helper will ensure all files and documents within are complete and signed by parents.Licensee will submit proof to LPA by email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 11/19/2021
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https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Applicant is advised to regularly visit the Community Care Licensing WEB SITE: http://www.ccld.ca.gov/ for quarterly updates and updated regulation information. Duty Line was provided: (619) 767-2248.Southern California Child Care Advocate information was provided and applicant was encouraged to subscribe through the CCLD website in order to be placed on an email list for updated regulation information. Advocate information was provided: (714) 703-2800 or childcareadvocatesprogram@dss.ca.gov.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/communitycare-licensing/inspection-process.

Exit interview conducted and report was reviewed with the licensee. See 809-D for Type B deficiency cited.

A Notice of Site Visit was given and must remain posted for 30 days
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
LIC809 (FAS) - (06/04)
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