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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376623903
Report Date: 04/17/2025
Date Signed: 07/09/2025 08:11:46 AM

Document Has Been Signed on 07/09/2025 08:11 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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:KHOURY, ARLETTE FAMILY CHILD CAREFACILITY NUMBER:
376623903
ADMINISTRATOR/
DIRECTOR:		ARLETTE KHOURYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(858) 775-8725
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
04/17/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Arlette Khoury TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 4/17/25 at 12 pm Licensing Program Analyst (LPA) Gerald Poindexter conducted an unannounced annual inspection. Upon arrival, LPA met with licensee Arlette Khoury. Also, in the home was licensee’s helpers Farzana Kamandy, Shokria Nawaey, and Monika Staiger. Present in the home were 10 day care children, 3 of whom were under 24 months. Operating hours are from 8 am to 5 pm. The licensee was provided with the Inspection Checklist (LIC 126). The 3-bedroom, den, 2-bath, one-story floor home was toured and inspected to ensure an environment safe for the care and supervision of children.

The licensee has provided adequate space for the children to eat, sleep and play within the home. Areas used for child care include bedroom #2, den area, dining room, kitchen, covered patio area and hallway bathroom. Off limits areas include: master bedroom/bath, bedroom #1, laundry room and garage. Areas are inaccessible by having the doors closed and door locks (laundry room). The facility has sufficient toys and equipment available.

The home has a fully fenced, backyard/side yard play area available for outdoor activities. No hazards were noted. Outdoor play area has age-appropriate play equipment in good condition. The licensee understands that visual supervision is always required during outdoor activities. No body of water was observed during time of inspection.

There is a fully charged fire extinguisher, smoke and carbon monoxide detector that meet requirements and are operational. There is a fireplace that is screened and inaccessible to children. Poisons, cleaning

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NAME OF LICENSING PROGRAM MANAGER: Joelle Redding
NAME OF LICENSING PROGRAM ANALYST: Gerald Poindexter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2025
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.

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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: KHOURY, ARLETTE FAMILY CHILD CARE
FACILITY NUMBER: 376623903
VISIT DATE: 04/17/2025
NARRATIVE
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compounds, medications and other hazardous items were made inaccessible to children via latches/locks or high placement. Adequate heating and ventilation are provided, and vents are located near the ceiling. There is a working telephone and email address. Licensee stated there are NO firearms, weapons or ammunition in the home.

LPA observed all required postings were posted. Children’s records were reviewed and found to be incomplete. Staff records were reviewed and found to be incomplete. Licensee has the required immunizations per SB792. Licensee’s helpers Ms. Komandy and Ms. Staiger did not have immunizations on file at the time of inspection. Licensee’s and licensee’s helper’s Pediatric CPR/First Aid are current with an expiration date of 2/2026 (Ms. Khoury) and 10/2025 (Ms. Nawaey). Preventative health practices course was completed. Licensee and licensee’s helper Ms. Nawaey’s Mandated Reporter Training Certificates per AB1207 expire 1/8/26 and 1/14/26, respectively. Ms. Staiger did not have a Mandated Reporter Training Certificates on file at the time of inspection. LPA reminded licensee that it must Pediatric CPR/First Aid and Mandated Reporter Training Certificates shall be renewed every 2 years.

Emergency drills are conducted and documented with the last one being on 3/17/25. Licensee maintains a current roster of the children which LPA obtained during time of inspection. LPA verified that all adults living or working in the home have been fingerprint cleared and associated. LPA reminded Licensee that all unusual incident reports shall be submitted to Licensing office via email at SDIncidentReports@dss.ca.gov or via fax at (619)767-2203. Duty officer number is (619) 767-2248.



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 and licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

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
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NAME OF LICENSING PROGRAM MANAGER: Joelle Redding
NAME OF LICENSING PROGRAM ANALYST: Gerald Poindexter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
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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: KHOURY, ARLETTE FAMILY CHILD CARE
FACILITY NUMBER: 376623903
VISIT DATE: 04/17/2025
NARRATIVE
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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 conducted child care quality management staff interview with the licensee. 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-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 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.

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.

See LIC809D for deficiencies cited.



Exit interview conducted and report was reviewed with the licensee, Arlette Khoury. During the exit interview, the licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. A Notice of Site Visit was given and must remain posted for 30 days. Appeal Rights provided.
NAME OF LICENSING PROGRAM MANAGER: Joelle Redding
NAME OF LICENSING PROGRAM ANALYST: Gerald Poindexter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/09/2025 08:11 AM - It Cannot Be Edited


Created By: Gerald Poindexter On 04/17/2025 at 02:16 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: KHOURY, ARLETTE FAMILY CHILD CARE
FACILITY NUMBER: 376623903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
(g) The licensee shall document each child's immunizations 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 is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in the case of 2 of 10 children in care, children C1 and C2. Not maintaining immunization records for children poses a potential health, safety or personal rights risk to persons in care..
POC Due Date: 05/01/2025
Plan of Correction
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The licensee stated that she will provid a completed immunization records missing for children that was not on file and submit a copy to the LPA by 5/1/25. Email to Gerald.Poindexter@dss.ca.gov
Type B
Section Cited
CCR
102421(d)
102421 Child's Records: (d) In any case in which the licensee cares for an additional child pursuant to Section 102416.5(b) for a Small Family Child Care Home or Section 102416.5(d) for a Large Family Child Care Home, the licensee shall maintain, in the child's record, proof of parent notification that the facility is caring for an additional child as required in Section 102416.5(h).
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 10 out of 10 children's files reviewed do not contain a completed LIC9150, Parent Notification of Additional Children in Care form. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2025
Plan of Correction
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The licensee states that she will submit signed and completed Notification of Additional Children in Care forms, LIC9150 for all children via email by 5/1/25.
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: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/09/2025 08:11 AM - It Cannot Be Edited


Created By: Gerald Poindexter On 04/17/2025 at 02:16 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: KHOURY, ARLETTE FAMILY CHILD CARE
FACILITY NUMBER: 376623903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
(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 as 7 of 10 children were missing LIC627 form Consent for Emergency Medical Treatment, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2025
Plan of Correction
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The licensee states that she will submit signed and completed LIC627 forms, LIC9150, Consent for Emergency Medical Treatment, for all children via email by 5/1/25.
Type B
Section Cited
CCR
102417(m)(3)
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state. 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 as 10 of 10 were missing LIC282 form Affadavit Regarding Liability Insurance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2025
Plan of Correction
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The licensee states that she will submit signed and completed LIC282 form Affadavit Regarding Liability Insurance for all children via email by 5/1/25.
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: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 07/09/2025 08:11 AM - It Cannot Be Edited


Created By: Gerald Poindexter On 04/17/2025 at 02:16 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: KHOURY, ARLETTE FAMILY CHILD CARE
FACILITY NUMBER: 376623903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on record review licensee did not have a Mandated Reporter certificates on file for 1 of 3 staff present, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2025
Plan of Correction
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Licensee stated that they will provide the Mandated Reporter Training certificate no later than 5/1/25.
Mandated Reporter online website address is: mandatedreporterca.com
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on record review, the licensee did not comply with the section cited above in the caseof 2 of 3 staff present, S1 and S2, were missing vaccine records. Not maintaining immunization records poses a potential health, safety or personal rights risk to persons in care..
POC Due Date: 05/01/2025
Plan of Correction
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The licensee stated that she will provid a completed immunization records missing for staff that was not on file and submit a copy to the LPA by 5/1/25. Email to Gerald.Poindexter@dss.ca.gov
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: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2025


LIC809 (FAS) - (06/04)
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