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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629428
Report Date: 01/22/2025
Date Signed: 01/23/2025 07:44:38 AM

Document Has Been Signed on 01/23/2025 07:44 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 CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:KASIM, SHAMI FAMILY CHILD CAREFACILITY NUMBER:
376629428
ADMINISTRATOR/
DIRECTOR:		SHAMI KASIMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 642-5645
CITY:SAN DIEGOSTATE: CAZIP CODE:
92105
CAPACITY: 14TOTAL ENROLLED CHILDREN: 2CENSUS: 2DATE:
01/22/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Shami Kasim TIME VISIT/
INSPECTION COMPLETED:
03:55 PM
NARRATIVE
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On 1/22/2025, at 12:40 p.m., Licensing Program Analyst (LPA), Victoria Hernandez conducted an unannounced Annual Inspection and met with Licensee assistant Halima Bukuru Kassim while we waited for Licensee to arrive from store. LPA disclosed the purpose of the inspection and was led on a tour of the facility indoors and outdoors. This facility is a one story, four-bedroom, two-bathroom house. The following areas are used for childcare: Living room, bedroom #1, bathroom #1, and front yard. Off limits areas include: kitchen, garage, bedrooms #2, #3, ,and #4, bathroom #2 and backyard which are made inaccessible through the use of safety gates, locks and doorknob covers. Hours of operation hours are Monday – Sunday, 6:00 a.m. to 11:00 p.m. There was two (2) preschool child present during the inspection. At 1:45 p.m., Licensee Shami Kasim arrived to facility.

The fire extinguisher, smoke detector and carbon monoxide detector met requirements. LPA informed licensee poisons shall be placed in a storage area and locked. LPA did not observe toys and materials available for children’s use. Licensee utilizes fully fenced front yard for outdoor activities/. LPA informed licensee to ensure children are supervised at all times during outdoor activities. There is no fireplace on the premises. Licensee stated there are no bodies of water and LPA did not observe any bodies of water during the inspection. Licensee stated there are no firearms, other weapons, or ammunition 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. LPA did not review any children’s file. Licensee did not have her files readily available to view.

Licensee’s Mandated Reporter AB1207 training is exempt due to English not being primary language. Pediatric CPR and First Aid certifications expire on 12/2026. Licensee has required immunizations, per file review. Facility roster is maintained and was reviewed. The licensee conducted and documented a fire and disaster drill on 10/12/2024. Required documents are posted. (CONT 809C...)
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Victoria Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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 6
Document Has Been Signed on 01/23/2025 07:44 AM - It Cannot Be Edited


Created By: Victoria Hernandez On 01/22/2025 at 01:47 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: KASIM, SHAMI FAMILY CHILD CARE
FACILITY NUMBER: 376629428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in face heaters shall be screened to prevent access to children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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Licensee stated she shall screen the face heater located in bedroom #1 to prevent access to children.
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation , the licensee did not comply with the section cited above in cleaning compunds were readily available to children which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Licensee moved cleaning compounds that were readily available to children to an inaccessible location out of reach of children.
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:Jason Garay
LICENSING EVALUATOR NAME:Victoria Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/23/2025 07:44 AM - It Cannot Be Edited


Created By: Victoria Hernandez On 01/22/2025 at 01:47 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: KASIM, SHAMI FAMILY CHILD CARE
FACILITY NUMBER: 376629428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in licensee assistant did not have staff file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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Licensee stated she will provide LPA with assisants file which will include immunization record, mandated reporter training, LIC 9108, LIC 9052, and CPR
Type B
Section Cited
CCR
102368(a)
License
(a) The license shall be available in the facility upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in license shall be avaiable in the facility upon request which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Licensee spoke to LPA on phone while explaining where files were at. Arrived 40 minutes after LPA arrived.
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:Jason Garay
LICENSING EVALUATOR NAME:Victoria Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/23/2025 07:44 AM - It Cannot Be Edited


Created By: Victoria Hernandez On 01/22/2025 at 01:47 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: KASIM, SHAMI FAMILY CHILD CARE
FACILITY NUMBER: 376629428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in not having an emergency information card for any of the children in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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Licensee stated she will submit childrens file to LPA
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in not being able to locate current roster of children which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Licensee was able to locate roster
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:Jason Garay
LICENSING EVALUATOR NAME:Victoria Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


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 CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KASIM, SHAMI FAMILY CHILD CARE
FACILITY NUMBER: 376629428
VISIT DATE: 01/22/2025
NARRATIVE
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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 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.

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/.

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-and-resources/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.
Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the licensee, Shami Kasim , confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
LPA reviewed with licensee 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.
LPA and licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov. LPA discussed and provided Licensee with the following: childcare advocates email address: childcareadvocatesprogram@dss.ca.gov. In addition, for general questions or questions licensing requirements contact the Child Care Licensing Duty Line at (619) 767-2248. (CONT 809C...)
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Victoria Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
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 CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KASIM, SHAMI FAMILY CHILD CARE
FACILITY NUMBER: 376629428
VISIT DATE: 01/22/2025
NARRATIVE
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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 platform. 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.

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.

Per California Code of Regulations, (Title 22, division 12 & Chapter 3) six (6) Type B is being cited on the attached LIC 809-D.
A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and report was reviewed with the licensee, Shami Kasim.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Victoria Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
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