Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627064
Report Date: 04/17/2019
Date Signed: 04/17/2019 06:07:16 PM

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:MARYAM H,& GHOLAMI GHOLAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 792-8995
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:14CENSUS: 5DATE:
04/17/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:31 PM
MET WITH:Maryam HoseiniTIME COMPLETED:
06:20 PM
NARRATIVE
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Licensing Program Analyst (LPA), Vicky Williamson conducted an unannounced case management inspection. LPA met with Licensee, Maryam Hoseini. Also present was licensee's daughter Zahra Gholami who aided as a translator due to licensee's primary language being Farsi. There was 5 children present during the time of inspection. During the inspection, LPA reviewed Children's Record and observed that records for 3 day care children were not available for review. Licensee acknowledged that records were not available for child #1, child #2 & child #3. Licensee was advised that prior to enrolling children at the facility the required forms must be completed and available for LPA's review of records. Licensee stated that she understood.

See LIC 809D for issued deficiencies. LPA reviewed this report with Licensee Maryam Hoseini. The licensee was provided a copy of her appeal rights (LIC 9058 01/16) and her 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.
SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2214
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2019
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2019
Section Cited
CCR
102417(g)(7)
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The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to:An emergency information card shall be maintained for each child and shall include the child's full name,
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Licensee will complete records for child #1, child #2, child #3 and provide proof of children records to the Department, no later than 4/19/19.
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telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. The requirement is not met as evdence by: Children records were not available for child #1,#2 & #3. This poses a potential health and safety risk to 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: 04/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2019
LIC809 (FAS) - (06/04)
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