Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627064
Report Date: 05/16/2018
Date Signed: 05/16/2018 11:22:56 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:
05/16/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Maryam Hoseini & Gholam GholamiTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vicky Williamson made an unannounced Annual/Random inspection. Met with Licensee, Maryam Hoseini and Co-Licensee Gholam Gholami. Also present was applicant’s son Alireza Gholami who assisted with Farsi translation. During this inspection there was 1 child in care.

On 5/09/18, a fire clearance was granted for 14 children. This single level, 4 bedrooms, 2 bathroom home was inspected. The following areas will be used for child care: kitchen, dining room, living room, family room, bathroom 2, and fully fenced backyard. Off limits areas: bedroom 1, bedroom 2, bedroom 3, bedroom 4, garage and front yard. The following areas are made inaccessible to children through the use door locks. There is a fireplace in the home located in an off limits area (living room). There were no bodies of water observed during the time of inspection. There is a working fire extinguisher rated 2A 10B:C located in the kitchen, smoke and carbon monoxide detector are present and operational. Poisons, cleaning compounds, medications and other hazardous items are inaccessible to children due to being placed in inaccessible areas. Adequate heating and ventilation is provided for day care children. Children’s toys, play equipment and materials are available. Licensee states there are NO firearms or weapons in the home. Licensee maintains a current facility roster of the children, which LPA obtained during time of inspection. Children’s records for child #1, who was present during time of inspection were not available for review. All other children files were reviewed and are in compliance. License states that a copy of the Family Child Care Notification of Parent Right’s is provided to parents. Pediatric CPR/First Aid certifications for Licensee (Maryam) is valid through 5/2020 and Co-Licensee (Gholam) is valid through 4/10/19. Last fire/disaster drill conducted on 5/15/18. Licensee's are exempt from Mandated Reporter AB1207 training certification due to them having limited English proficiency, both licensees' primary language is Farsi.

Licensee stated there are no new adults living in the home over the age of 18 years. A review of staff records on 5/16/18 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances.
SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2214
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2018
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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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: 05/16/2018
NARRATIVE
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LPA advised licensees 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
LPA reviewed the following with licensees': SIDS, car seat law, reporting requirements and shaken baby syndrome. Licensees were also reminded the following items are prohibited during day care operating hours (walkers, exersaucers, jumpers and bouncy seats). Corporal punishment and smoking are not allowed in the day care.

Licensees are currently not providing IMS to children in 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.html

New immunization law (SB792) was discussed with Licensees. Licensees understand that anyone who provides care and supervision to the children must have immunization records maintained at the facility for: pertussis, measles, and influenza.

LPA reviewed this report while licensees' son interpreted and explained inspection report to licensees' in Farsi, both licensees stated they understood. An exit interview was conducted. Licensees were provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS. LPA observed Licensee post notice of site visit. Access our updated Regulation & Forms by using our WEBSITE: http://ccld.ca.gov

The maximum capacity for a large family child care home: 4 infants only (infants mean any children under 24 months); or 12 children with no more than 4 infants; or 14 children with no more than 3 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.
A Regular Large Family Child Care Home license maybe issued for 14 children upon final file review.
Licensee and Co-Licensee maintain control of property and have provided proof to the Department.
SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2214
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2018
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2018
Section Cited
CCR
102421(a)(b)
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Childs Records. The licensee shall maintain, in each child’s record, the signed and dated notice form LIC 995A, Parents Rights Notice. The licensee shall maintain, in each child’s record, a copy of the emergency information card required in Section 102417(g) (7).
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Licensees stated they will submit records for child #1, no later than 5/25/18.
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Records for Child #1 was not available for review during time of inspection. This poses a potential risk to the health and safety of 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: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2214
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2018
LIC809 (FAS) - (06/04)
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