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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376101739
Report Date: 11/29/2023
Date Signed: 11/29/2023 10:33:38 AM

Document Has Been Signed on 11/29/2023 10:33 AM - 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:SAMADI, MOHAMMAD FAMILY CHILD CAREFACILITY NUMBER:
376101739
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
11/29/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Mohammad SamadiTIME COMPLETED:
10:50 AM
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On November 29, 2023 at 8:35 a.m. Licensing Program Analyst (LPA) Leilani Curtis conducted an announced change of location and capacity increase pre-licensing inspection with applicant, Mohammad Samadi. The purpose of the inspection is to ensure that the home is in compliance with standards established in CCR, Title 22, Division 12, Chapter 3. This 3 bedroom, 2 bathroom home was toured and inspected to ensure an environment safe for the care and supervision of children. Because the applicant rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149). The home appears to be large enough to comfortably accommodate 14 children. An approved fire clearance was received on 11/2/23.

Applicant will use the following areas for child care: living room #1, living room #2, kitchen, bedroom #1, bedroom #2, bedroom #3, bathroom #1, bathroom #2 and enclosed rear yard. There are no off limits areas within the home. The front yard is off-limits. There are no stairs in the home. Applicant will utilize the enclosed rear yard for outdoor activities. There are no bodies of water observed during time of visit. The fire extinguisher, smoke and carbon monoxide detector meet requirements and are operational. LPA observed that there is no furniture, except for a dining table, or clothing in the home. The applicant states that he has not moved into the home yet. The bathroom cabinets and drawers are empty but have locks and/or latches on them. LPA observed that the kitchen cabinets and drawers have some items in them, and items that are hazardous are inaccessible to children through latches, locks, and/or placed up on high surfaces.

SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: SAMADI, MOHAMMAD FAMILY CHILD CARE
FACILITY NUMBER: 376101739
VISIT DATE: 11/29/2023
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Children’s toys and play equipment are available. Applicant states there are NO firearms or other weapons in the home. Applicant has completed the 8 hours of preventative health training. Pediatric CPR and First Aid certifications expire in January 2024. Applicant has completed the Mandated Child Abuse Reporting-per AB1207. LPA reviewed certification and it is in compliance. Required documents are posted. 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. Immunization records per SB792 were reviewed and are in compliance for all personnel that will be providing care and supervision to children. Applicant is reminded to make anything that reads, "Keep Out of Reach of Children" inaccessible to children.

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) or (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.

The New Provider Resource Packet was reviewed with the applicant including information on the following: SIDS, shaken baby syndrome, effects of lead, insurance, child abuse reporting, community resources, immunization's, car seat law, visual for ratio/capacity, prohibited items handout (walkers, exersaucers, jumpers and bouncy seats), fire/disaster drill log, 15-minute safe sleep log and the YMCA Resource Center. The applicant was also reminded that corporal punishment and smoking are not allowed in the day care. LPA discussed California Megan's Law and provided: www.meganslaw.ca.gov.

On this date, 10/19/2023, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
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: SAMADI, MOHAMMAD FAMILY CHILD CARE
FACILITY NUMBER: 376101739
VISIT DATE: 11/29/2023
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Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 applicant and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep, as an additional resource. LPA also informed applicant 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.

LPA reviewed with applicant the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

Applicant was informed of the MyChildCarePlan.org site, 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
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: SAMADI, MOHAMMAD FAMILY CHILD CARE
FACILITY NUMBER: 376101739
VISIT DATE: 11/29/2023
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Prior to licensure the following will be corrected:
  • The applicant must move his furniture and belongings into the home and actively live in the residence.

Applicant states that he will submit a video and photographs of each room of the home, including closets and drawers, verifying that he has moved into the home, to LPA via email by Friday, December 1, 2023. Once the correction has been received a large license of a capacity of 14 children may be issued.

Exit interview conducted and report was reviewed with the applicant.

A notice of site visit was given to applicant and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
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