<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376628597
Report Date: 09/14/2023
Date Signed: 09/14/2023 12:49:13 PM

Document Has Been Signed on 09/14/2023 12:49 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:ADAN, MANIRA FAMILY CHILD CAREFACILITY NUMBER:
376628597
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
09/14/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Manira AdanTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On September 14th, 2023, at 11:45 AM, Licensing Program Analyst (LPA) Jo Ann Legaspi conducted a capacity increase inspection. Licensee Manira Adan was advised of the inspection’s purpose and granted LPA facility entry. The inspection’s purpose is to ensure that the home follows standards established in CCR, Title 22, Division 12, Chapter 3, for Family Child Care Homes. Present in the home was the Licensee, Fariyo Omar (background cleared) and two (2) children. This one (1) story, five (5) bedroom, three (3) bathroom house was toured and inspected.

On 07/17/2023, Licensee submitted an application (LIC 279) requesting a capacity increase. The Fire Safety Inspection Request (STD 850) was approved by the local fire marshal on 09/07/2023 for fourteen (14) children. Landlord consent is not on file. Licensee provided a written statement which states they will care for only twelve (12) children or less.

The off-limits areas are the kitchen, remaining bedrooms, remaining bathrooms and the backyard. Kitchen cabinets have cabinet locks. Door locks are on the doors to the backyard, remaining bedrooms and bathrooms. The following rooms are used for care: living room, dining room, one bedroom and one bathroom.

Licensee accompanied LPA on a tour of the home, as shown on the updated facility sketch. Background criminal record clearances were verified and discussed. First Aid and CPR certifications expire on 11/26/2023. The facility has a working fire extinguisher, smoke and carbon monoxide detector. The last safety drill was on 07/20/2023. Licensee states there are no bodies of water on the premises, and none were observed. Per the Licensee, neither weapons nor ammunition are stored on the facility premises.

The Licensee has provided proof of control of property. The licensee has not obtained a signed Property Owner/Landlord Consent form (LIC9149). Without this consent, the licensee understands that, once licensed,
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: ADAN, MANIRA FAMILY CHILD CARE
FACILITY NUMBER: 376628597
VISIT DATE: 09/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
they can operate with a maximum capacity of 12 children. If property owner/landlord consent is obtained in the future, the licensee is advised that a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 14 children.

The Licensee and LPA reviewed the Ratio/Capacity Worksheet for a large family childcare home. The Licensee acknowledged that if no assistant provider is present at a Large Family Child Care Home, then the Licensee shall comply with the capacity requirements for a Small Family Child Care Home. Licensee has an intended helper who has already completed the background clearance prior to their initial presence in a Family Child Care home. The helper has a current pediatric 1st Aide/CPR card, Mandated Reporter Training completion certificate, documentation of their necessary vaccinations and medical clearance. Licensee acknowledges that their assistant's records will be maintained in the daycare for review by the Department.

The Licensee and adult residents in the home have criminal record clearances and/or exemptions on file. Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and adults who have contact with children, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.



In the areas that were evaluated, no deficiencies were observed. Licensure for a capacity of twelve (12) children is approved effective today 09/14/2023. A new license will be generated and mailed to the provider.

Notice of site visit was given to the licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview was conducted and report was reviewed with the Licensee Manira Adan.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2