Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627064
Report Date: 09/06/2017
Date Signed: 09/06/2017 11:44:07 AM

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:GHOLAMI, GHOLAM & HOSEINI, MARYAM FCCFACILITY NUMBER:
376627064
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 1DATE:
09/06/2017
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Maryam Hoseini & Gholam GholamiTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Samantha Salunga conducted an announced Pre-Licensing inspection with applicant's, Maryam Hoseini & Gholam Gholami. Also present was Alireza Gholami, Applicant's daughter (who acted as Farsi translator during inspection) and son. Purpose of the visit is to ensure that the home is in compliance with standards established in CCR, Title 22, Division 12, Chapter 3. This 4 bedroom, 2 bath home was toured and inspected to ensure an environment safe for the care and supervision of children. Applicant's own the facility and has provided proof by grant deed. Applicant's will use the following areas for child care: hallway bathroom, kitchen/dining room, living room and family room. Off limits areas include: garage and all bedrooms and one bathroom. Applicant's will utilize fully fenced backyard for outdoor activities. There are no bodies of water observed during time of visit. The fire extinguisher, smoke and carbon monoxide detector meet requirements and are operational. All poisons, cleaners and hazardous items in the home are inaccessible to children through latches, locks, and/or placed up on high surfaces. Children’s toys and play equipment are available. Applicant's states there are no firearms or other weapons in the home. Applicant's has completed the 8 hours of preventative health. Pediatric CPR and First Aid certifications expire on April 10, 2017 (Gholam) and May 2018 (Maryam). Required documents are posted. Applicant's, Alireza Gholami, and Hosein Gholami are the only adults residing in the home and have been cleared for criminal record and child abuse index clearances. Applicant's were advised that any new/additional adults must be cleared prior to working or residing in home. Any minor upon his/her 18th birthday must be fingerprinted within 30 days. Immunization records per SB792 was reviewed and in compliance for all personnel that will be providing care and supervision to children.
SUPERVISOR'S NAME: Carolina RamosTELEPHONE: (619) 767-2206
LICENSING EVALUATOR NAME: Samantha SalungaTELEPHONE: (619) 767-2209
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2017
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: GHOLAMI, GHOLAM & HOSEINI, MARYAM FCC
FACILITY NUMBER: 376627064
VISIT DATE: 09/06/2017
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The New Provider Resource Packet was reviewed with the applicant including information on the following: SIDS, shaken baby, insurance, child abuse reporting, community resources, children’s records/facility records/required postings, immunization's, unusual incident report, roster, car seat law, visual for ratio/capacity, prohibited items handout (walkers, exersaucers, jumpers and bouncy seats), fire/disaster drill log, and the YMCA Resource Center. Applicant was also reminded that corporal punishment and smoking are not allowed in the day care.

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

The maximum capacity for a small family child care home: 4 infants only (infants mean any children under 24 months); or 6 children with no more than 3 infants; or (with landlord consent) 8 children with no more than 2 infants, 1 child in kindergarten or elementary school and 1 child at least age 6 including children under age 10 who live in the licensee's home. To access our Regulations and Forms please use our WEBSITE: http://ccld.ca.gov

***A Regular Small Family Child Care Home License is granted and effective today’s date 09/06/17.
SUPERVISOR'S NAME: Carolina RamosTELEPHONE: (619) 767-2206
LICENSING EVALUATOR NAME: Samantha SalungaTELEPHONE: (619) 767-2209
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2017
LIC809 (FAS) - (06/04)
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