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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100575
Report Date: 01/23/2025
Date Signed: 01/23/2025 02:55:52 PM

Document Has Been Signed on 01/23/2025 02:55 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: 20CENSUS: 5DATE:
01/23/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Khalif, Samsam and Anab ElmiTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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On 1/23/25 at 12:40 PM Licensing Program Analyst (LPA) Adriana Macias conducted an unannounced annual inspection. Upon arrival, LPA identified herself and provided badge to Licensee Samsam Khalif. Also present was helper Anab Elmi. Two other adults where hired to clean the off-limits areas. Licensee states that they are never in contact with the children when she requests cleaning services. LPA suggested that cleaning services be done not during day care hours, when children are not in the home, to avoid contact. The one story single family home, was toured and inspected to ensure an environment safe for the care and supervision of children. There were 5 children in care. One parent picked up one of the children at around 1:30 pm. Licensee stated she has 20 children enrolled. At around 2:30, licensee had to leave to a doctor’s appointment, which she stated she would be back by 4:00 pm, leaving her helper behind to take care of the 4 children left.

Licensee has provided adequate space for the children to eat, sleep and play within the home. Areas used for child care include the Living Room, Family Room, Bedroom 2, the bathroom attached to Bedroom 2, Bedroom 3 and hallway bathroom. Off limits areas include the Kitchen, Laundry Room, Garage, Master Bedroom and bathroom, and the Den room. These areas are all inaccessible to children by the use of doorknob covers except for the kitchen. Licensee stated that the kitchen door has recently broken and they are working on replacing it. Fully fenced backyard is used for outdoor playtime. Licensee understands that supervision is required at all times during outdoor activities.


The fire extinguisher, 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 in the home. Licensee states that there are no weapons in the home.

Licensee’s First Aid and CPR certifications expire on Oct, 2025 and helper’s First Aid and CPR certifications expire on Oct, 2025. Licensee and helper have required immunizations. Licensee’s Mandated Reported Training Certificates is not on file. Licensee states she has completed it last year but that she does not have the copy. Licensee stated she will send a copy to LPA Adriana Macias within 5 business days. The helper is exempt from Mandared Reporter Training as their primary language is Somali. Licensee’s immunization requirements were met as well as for other adults living at home. All adults living in the home, have received criminal record and child abuse clearances or exemptions.
Tashima DanielTELEPHONE: (619) 767-2242
Adriana MaciasTELEPHONE: (619) 767-2217
DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 376100575
VISIT DATE: 01/23/2025
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Provider is hereby reminded of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms; 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 reviewed with Licensee the LIC 311D, Forms/Records. To Keep In Your Family Childcare Homes, children’s forms/records, facility forms/records, and information to be posted.

LPA discussed and provided Licensee with the following: childcare advocates-email address: childcareadvocatesprogram@dss.ca.gov . In addition, for general questions or questions regarding licensing requirements contact the Childcare Licensing Duty Line at (619) 767-2248.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/community-care-licensing/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [or facility representative] 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.

SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Adriana MaciasTELEPHONE: (619) 767-2217
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KHALIF, SAMSAM FAMILY CHILD CARE
FACILITY NUMBER: 376100575
VISIT DATE: 01/23/2025
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.



During the exit interview, the helper confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

See 809D page for Type B violations.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee’s helper Anab Elmi. Appeal Right were also printed and issued to the helper.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Adriana MaciasTELEPHONE: (619) 767-2217
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2025 02:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 376100575

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 4 out of 5 children records, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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Licensee stated that she would have files ready by POC date, and that she would have one of her helpers help her with the adminitrative side of her day care.
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 5 children records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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Licensee stated that she would have files ready by POC date, and that she would have one of her helpers help her with the adminitrative side of her day care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tashima DanielTELEPHONE: (619) 767-2242
Adriana MaciasTELEPHONE: (619) 767-2217

DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025

LIC809 (FAS) - (06/04)
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