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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100222
Report Date: 09/19/2023
Date Signed: 09/19/2023 05:33:18 PM

Document Has Been Signed on 09/19/2023 05:33 PM - 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 N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:MOHAMED, SAMSAM FAMILY CHILD CAREFACILITY NUMBER:
376100222
ADMINISTRATOR:SAMSAM MOHAMEDFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 436-6344
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
09/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:42 PM
MET WITH:Samsam MohamedTIME COMPLETED:
05:40 PM
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On 9/19/23 at 3:42 PM, Licensing Program Analyst (LPA) Keturah Lane conducted an unannounced annual inspection with the Licensee. Upon arrival, LPA met with Licensee, Samsam Mohamed and provided the Inspection Checklist (LIC126). The one-story apartment home located on ground level, was toured and inspected to ensure an environment safe for the care and supervision of children. Present were the Licensee, and two school-age daycare children. Proper supervision, ratios and capacity were observed. The fire extinguisher, carbon monoxide detector, and smoke detector meet requirements and are operational. All hazardous items were latched/locked and secured out of reach of children. The apartment complex has a swimming pool with fencing that meets regulations and is locked. Licensee stated she does not allow the daycare children to use the pool. Licensee states that there are no weapons 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.

Licensee has provided adequate space for the children to eat, sleep and play within the home. Areas used for childcare include: living room, kitchen, dining room, bathroom #1 and master bedroom. Off limits areas include: bedroom #2 and bathroom #2 which is inside the master bedroom but inaccessible by use of a safety gate. Other off-limit areas (bedroom #2) are inaccessible by use of door-knob covers. There is a working phone at the facility. The licensee has sufficient age appropriate, safe, toys and equipment available. Licensee takes the children to a nearby park for outdoor activities and understands visual supervision is required at all times. Verification of control of property is on file. Property owner/Landlord notification is on file. Landlord consent is not on file.
(continued on LIC809-C...)
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: MOHAMED, SAMSAM FAMILY CHILD CARE
FACILITY NUMBER: 376100222
VISIT DATE: 09/19/2023
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Licensee’s First Aid and CPR certifications expired. Licensee is currently enrolled with American Red Cross to update her CPR/First Aid. Licensee meets immunization requirements. Mandated reporter training expired 3/14/20. Licensee was not aware she needed to renew it every two years. Licensee stated she will renew her mandated reporter training and keep it on file. Licensee maintains emergency records for children. Required documents are posted. LPA reviewed documentation of emergency drills and last (earthquake/fire) drill was conducted on 8/13/23.

Provider is hereby reminded of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov. LPA Lane reviewed Covid-19 guidelines with Licensee and provided Covid-19 resources. LPA Lane directed Licensee to website: https://www.cdss.ca.gov/inforesources/community-care-licensing to receive important updates and information.

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.

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-andresources/safe-sleep as an additional resource. (continued on LIC809-C...)
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
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 N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: MOHAMED, SAMSAM FAMILY CHILD CARE
FACILITY NUMBER: 376100222
VISIT DATE: 09/19/2023
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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 child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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/.

No deficiencies cited at this inspection.



Exit interview conducted and report was reviewed with the licensee, Samsam Mohamed. Notice of Site Visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

During the exit interview, the Licensee, Samsam Mohamed confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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

SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC809 (FAS) - (06/04)
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