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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376628367
Report Date: 07/21/2021
Date Signed: 07/21/2021 02:42:25 PM

Document Has Been Signed on 07/21/2021 02:42 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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:ADAM, MULKI FAMILY CHILD CAREFACILITY NUMBER:
376628367
ADMINISTRATOR:MULKI ADAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 321-7110
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mulki AdamTIME COMPLETED:
03:00 PM
NARRATIVE
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On 7/21/21 at 2:00 PM, Licensing Program Analyst (LPA) Keturah Lane conducted an unannounced inspection with the Licensee. Upon arrival, LPA met with Licensee, Mulki Adam. The one-story apartment home on ground level was toured and inspected to ensure an environment safe for the care and supervision of children. There were no children in care. Licensee stated that she has not cared for children since the pandemic began last year. The fire extinguisher, carbon monoxide detector, and smoke 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 on the property. Licensee states that there are no weapons in the home. 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. Licensee’s First Aid and CPR certifications expire on 2/8/22. Licensee meets immunization requirements and has not renewed Mandated Reporter Training which expired 7/30/2020. Children’s records were not reviewed.

Licensee has provided adequate space for the children to eat, sleep and play within the home. Areas used for child care include: living room, dining room, kitchen, bathroom and bedroom. There are no off-limit areas. There is a working phone at the facility. The licensee has sufficient age appropriate, safe, toys and equipment available. Licensee stated she would take the children to a nearby park for outdoor activities and understands visual supervision is required at all times during outdoor play.

(Continued on LIC809C...)
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2021
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: ADAM, MULKI FAMILY CHILD CARE
FACILITY NUMBER: 376628367
VISIT DATE: 07/21/2021
NARRATIVE
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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, ensure that all adults living or working in the home have criminal background clearances to avoid civil penalties associated with this requirement; 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. LPA Lane reviewed Covid-19 guidelines with Licensee and provided Covid-19 resources. LPA Lane directed Licensee to website: https://www.cdss.ca.gov/inforesources/community-care-licensing to receive important updates and information.

Incidental Medical services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm.

Pursuant to Title 22 of the CA Code of Regulations, the following Type B deficiency was cited (refer to LIC 809-D).

An exit interview was conducted with the Licensee. The Licensee was provided a copy of their appeal rights (LIC 9058) along with the report (LIC809) and their signature on this form acknowledges receipt of these rights. The LIC 9213 (Notice of Site visit) was posted during today's visit. Notice of Site Visit must remain posted for 30 days.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/21/2021 02:42 PM - It Cannot Be Edited


Created By: Keturah Lane On 07/21/2021 at 02:29 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: ADAM, MULKI FAMILY CHILD CARE
FACILITY NUMBER: 376628367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2021
Section Cited
HSC
1596.8662(4)(b)(1)

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1596.8662 - …training for mandated reporter who is licensed day care provider…(b)(1)On or before March 30, 2018, a person who…is a licensed child care provider…or employee of a licensed child care facility shall complete the mandated reporter training…This requirement was not met as evidenced by…
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Licensee stated she would send proof of renewal of the mandated reporter training (certificate) to LPA Lane by 8/4/21 via e-mail.
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Based on record review and licensee statement, licensee did not renew the mandated reporter training, which poses a potential health and safety 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.
SUPERVISOR'S NAME:Monica Cuddy
LICENSING EVALUATOR NAME:Keturah Lane
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2021


LIC809 (FAS) - (06/04)
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