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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376102118
Report Date: 09/16/2024
Date Signed: 09/16/2024 02:17:42 PM

Document Has Been Signed on 09/16/2024 02:17 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:KHADMI, MASOUMA FAMILY CHILD CAREFACILITY NUMBER:
376102118
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
09/16/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Masouma KhadmiTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 09/16/24 at 12 pm, Licensing Program Analyst (LPA) Gerald Poindexter identified himself and disclosed the nature of the visit before being granted entry. LPA Poindexter then conducted an announced pre-licensing inspection. LPA met with applicant, Masouma Khadmi. Also, present: Ahmad Haidari, the licensee’s husband. The 4-bedroom, 3-bath, 2-story home was toured and inspected to ensure an environment safe for the care and supervision of children. The applicant provided proof of control of property, a mortgage statement. Applicant states that they have sufficient financial resources to sustain the license.

Applicant will use the following rooms for childcare: Downstairs bedrooms 3 and 4, the downstairs bathroom, backyard patio (2nd floor). Either downstairs bedroom 3 or 4 will be used to care for/separate sick children. Off-limits areas include: the downstairs garage and all 2nd floor/upstairs areas. Access to stairs in the home are made inaccessible by safety gates. The garage is made inaccessible by a door lock and key latch. There are no bodies of water in the home. Applicant states she will use the upstairs back patio for outdoor activities and understands that continuous visual supervision is required.

There is a working phone at the facility. The fire extinguisher meets 2A10BC requirements. Carbon monoxide detector and smoke detector were tested and are operational. Poisons, cleaning compounds, medications and other hazardous items were latched/locked and secured out of reach of children. Heating and ventilation equipment were reviewed. The 2nd floor fireplace is screened. Applicant states there are NO firearms and weapons in the home. The applicant has age-appropriate toys and equipment available.

Pediatric CPR and First Aid card expire 4/6/26. Preventative health practices course (with lead poison prevention training) completed 4/2/24. Applicant’s Mandated Reporter AB1207 training certification expires 10/4/25. LPA reminded the applicant that the CPR/First card and Mandated Reporter should be renewed every two years. Staff /resident immunization requirements were met. All required health/safety and facility-related documents were visibly posted.
CONTINUED ON PAGE 2
SUPERVISORS NAME: Joelle Redding
LICENSING EVALUATOR NAME: Gerald Poindexter
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
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: KHADMI, MASOUMA FAMILY CHILD CARE
FACILITY NUMBER: 376102118
VISIT DATE: 09/16/2024
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Applicant 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 reviewed the following resources and information with applicant:
· LIC 311D, Forms/Records to Keep in Your Family Child Care Home, children’s forms/records, facility forms/records, and information required to be posted
· New provider packet, including unusual incident reporting procedures
· Rules related to children’s personal rights, child abuse, and prohibiting of corporal punishment
· Rules prohibiting smoking, walkers, exersaucers, jumpers and bouncy seats. Also, allowed/prohibited uses of car seats.
· Use of all equipment only as intended by the manufacturer
· Shaken Baby Syndrome and SIDS
· California Megan's Law and website: www.meganslaw.ca.gov
· COVID-19 and other communicable diseases guidelines and resources
· YMCA Resource Center information
· Additional CDSS contact information and provider resources

On this date, 9/16/24, 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. California Megan's Law and website: www.meganslaw.ca.gov
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SUPERVISORS NAME: Joelle Redding
LICENSING EVALUATOR NAME: Gerald Poindexter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
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: KHADMI, MASOUMA FAMILY CHILD CARE
FACILITY NUMBER: 376102118
VISIT DATE: 09/16/2024
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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.

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-and-resources/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.

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/.

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-care-licensing/subscribe and select the Child Care option to receive email communication.

No corrections are needed. A license for eight children may be granted upon final file review. Applicant agreed to comply with all regulations and laws governing family child-care homes. Exit interview conducted and report was reviewed with the applicant, Masouma Khadmi. Appeal rights provided.
SUPERVISORS NAME: Joelle Redding
LICENSING EVALUATOR NAME: Gerald Poindexter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC809 (FAS) - (06/04)
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