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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100575
Report Date: 05/08/2025
Date Signed: 05/08/2025 03:51:50 PM

Document Has Been Signed on 05/08/2025 03:51 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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:KHALIF, SAMSAM FAMILY CHILD CAREFACILITY NUMBER:
376100575
ADMINISTRATOR/
DIRECTOR:		SAMSAM KHALIFFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 228-3835
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
05/08/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Samsam KhalifTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 5/8/25 at 2:00 pm Licensing Program Analyst (LPA) Gerald Poindexter was conducting an inspection concerning another matter at the facility. LPA met with licensee Samsam Khalif. LPA discussed with Ms. Khalif the details surrounding an incident at the facility which took place on 4/25/25 and the regulations related to that matter. This incident was not reported to the Department as an Unusual Incident Report by the facility. Unusual Incident Reports shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. While requesting facility paperwork related to that incident, the licensee was unable to provide complete children’s forms (including immunization records), an updated facility roster, and complete employee records. Also, during the visit on this other matter, the LPA observed a crawling infant make contact with and partially dislodge a 4-panel room divider. The divider was installed between the family room/children’s play area and the living room, and intended to restrict access to the living room. LPA observed no injury to the child.

See LIC 809D for deficiencies cited.



Exit interview conducted and report was reviewed with the licensee, Samsam Khalif. A Notice of Site Visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Joelle Redding
NAME OF LICENSING PROGRAM ANALYST: Gerald Poindexter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/08/2025 03:51 PM - It Cannot Be Edited


Created By: Gerald Poindexter On 05/08/2025 at 02:25 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: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2025
Section Cited
CCR
102416.1(d)

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PERSONNEL RECORDS: (d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review. This requirement is not met as evidenced by:
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Licensee stated that she will create files for both helpers and send proof to the LPA by the POC due date. LPA provided document listing Helper Requirements. Email: Gerald.Poindexter@dss.ca.gov
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Based on record review and interview, the licensee had background clearances for, but not personnel files for helpers Vera Stone and Kos Osborne, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
05/15/2025
Section Cited
CCR102419(d)

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Admission Procedures and Parental and Authorized Representative's Rights: (d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by:
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Licensee stated that she will have parents provide complete paperwork. Licensee will submit proof by the POC due date. LPA provided LIC311D for review. Email: Gerald.Poindexter@dss.ca.gov
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Based on record review, Licensee was missing entire childrens files or had incomplete files for children in care which poses a potential Health, Safety, or 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.
Joelle Redding
NAME OF LICENSING PROGRAM MANAGER:
Gerald Poindexter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/08/2025 03:51 PM - It Cannot Be Edited


Created By: Gerald Poindexter On 05/08/2025 at 02:57 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: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2025
Section Cited
CCR
102418(g)

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IMMUNIZATIONS: The licensee shall document each Child's immunization as required by the California code of regulations, title 17, section 6070, and shall maintain such documentation for as long as the child is enrolled. This requirement was not met as evidenced by…
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Licensee stated that she will have parents provide immunizations for all children in care and understands that she will make sure that all forms are properly filled out and send proof to the LPA by the POC due date. Email: Gerald.Poindexter@dss.ca.gov
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Based on interview and record review, Licensee did not comply with the regulation above, she did not have immunizations for children in care. This poses a potential Health, Safety, or Personal Rights risk to children in care.
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Type B
05/22/2025
Section Cited
CCR102416.2(b)(3)(c)

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102416.2(b)(3)(c) "A report shall be made to the Department…following the occurrence during the operation of a family day care home of any of the following events:(C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child." This requirement was not met as evidenced by:
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LPA printed the reporting requirements regulation for the licensee, who stated she will ensure that any future incidents are reported to the duty line 619-767-2248 within 24 hours by phone and submitted within 7 days of the incident occurring via Unusual Incident Report by email to
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Based on record review and information gathered during another matter, the facility did not report to the Department an unusual incident on 4/25/25 to a daycare child, which poses a potential health, safety or personal rights risk to persons in care.
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SDIncidentReports@dss.ca.gov or by Fax at619-767-2203. Ms. Khalifa will also provide written statement to LPA at Gerald.Poindexter@dss.ca.gov by 5/22/25 explaining that she will submit future reports per the required time frames.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Joelle Redding
NAME OF LICENSING PROGRAM MANAGER:
Gerald Poindexter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/08/2025 03:51 PM - It Cannot Be Edited


Created By: Gerald Poindexter On 05/08/2025 at 03:06 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: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2025
Section Cited
CCR
102417(g)(8)

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Children’s Roster: (8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement is not met as evidenced by:
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Licensee states she will create and submit a complete roster of enrolled children and submit a copy to the Department by 5/22/25. Email: Gerald.Poindexter@dss.ca.gov
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Based on record review, the licensee did not comply with the section cited above, as the current roster of children was incomplete, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
05/22/2025
Section Cited
CCR102417(g)

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Operation of A Family Child Care Home: (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to...This requirement is not met as evidenced by:
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Licensee removed the room divider and stated that she will install a gate or other more secure barrier. The licensee will send LPA a photo by POC due date. Email: Gerald.Poindexter@dss.ca.gov
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LPA observed a crawling infant make contact with and partially dislodge a 4-panel room divider, which poses/posed a potential health, safety or personal rights risk to persons 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.
Joelle Redding
NAME OF LICENSING PROGRAM MANAGER:
Gerald Poindexter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2025


LIC809 (FAS) - (06/04)
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