Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627064
Report Date: 02/28/2018
Date Signed: 02/28/2018 10:38:23 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: 5DATE:
02/28/2018
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Gholami Gholami & Maryam HoseinTIME COMPLETED:
11:00 AM
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LPA Gloria Cruz made an unannounced case management visit and met with Licensees. Visit was interpreted by two adult sons who have criminal record and child abuse clearance. During visit LPA advised Licensees that Roster needed to be updated to include parents names and phone numbers and physicians names and phone numbers. Licensee states some of the children no longer attend but roster does not indicate date children started day care or date they left. Roster shall be updated and submitted to LPA within the next 10 days, on or before 3/10/18.

LPA discussed AB1207 Mandated Reporting and advised Licensees to complete training and submit certificates prior to 3/31/18.

LPA discussed with Licensee the need for verification of immunizations for any adults providing care and licensee is to submit verification to LPA within the next 10 days, on or before 3/10/18.

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
No deficiency is cited.
NOTICE OF SITE VISIT WAS POSTED AND MUST REMAIN POSTED FOR 30 DAYS
SUPERVISOR'S NAME: Jason GarayTELEPHONE: (559) 767-2250
LICENSING EVALUATOR NAME: Gloria CruzTELEPHONE: (619) 767-2238
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2018
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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