376100222-3-6-2026-51-CC-JDYE-DRWSD8-20260306124644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376100222
Report Date: 03/06/2026
Date Signed: 03/06/2026 12:47:54 PM

Document Has Been Signed on 03/06/2026 12:47 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 CARE		FACILITY NUMBER:	376100222
ADMINISTRATOR/ DIRECTOR:	SAMSAM MOHAMED		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(619) 436-6344
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92119
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 2	CENSUS: 0	DATE:	03/06/2026
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	SamSam Mohamed		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/06/2026 at 9:30am Licensing Program Analyst (LPA's) Jody Dye and Ryan Grimes conducted an unannounced inspection with the Licensee. LPA identified self, disclosed the purpose of the inspection and was granted entry into the facility by the Licensee Samsam Mohamed. Present in the home were the Licensee and no day care children. The one-story two-bedroom two-bathroom home was toured and inspected to ensure an environment safe for the care and supervision of children. Licensee accompanied LPA inside and out of the facility during this inspection. Licensee has past due fees in the amount of $ 630.00. Licensee was reminded of the overdue fees and provided her PIN number to pay online. 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, bedroom #1 (Master) and bathroom #1. Off limits areas include bedroom #2 and Bathroom #2. Bathroom #2 is inside the Master bedroom which is made inaccessible using a child safety gate. Bedroom #2 is made inaccessible using a child safety doorknob cover on the door handle. The licensee has sufficient toys and equipment available. Licensee see takes the children to a nearby park for outdoor activities. Licensee will always provide visual supervision when children are outdoors. The fire extinguisher, smoke detector, and carbon monoxide detector meet requirements and are operational. LPA observed chemicals under the sink in the accessible bathroom. Licensee only provides care for children on the weekends. Licensee was able to move the cleaning chemicals to a cabinet that is out of reach of children. All other hazardous items were latched/locked and secured out of reach of children. The home has central heat for climate control comfort. The home does not have a body of water. There is a community pool within the apartment complex. Licensee states children will not use the pool. Licensee states that there are no weapons in the home. Licensee stated does transport children. Continued on LIC 809-C page 2

NAME OF LICENSING PROGRAM MANAGER: Renesha Askew
NAME OF LICENSING PROGRAM ANALYST: Jody Dye
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/06/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2026

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 7

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 7

Document Has Been Signed on 03/06/2026 12:47 PM - It Cannot Be Edited

Created By: Jody Dye On 03/06/2026 at 11:32 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: MOHAMED, SAMSAM FAMILY CHILD CARE	FACILITY NUMBER: 376100222
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)1

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the licensee did not comply with the section cited above. The licensee had not completed or documented a disaster drill with children since 08/13/2023, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/13/2026
	Plan of Correction
1 2 3 4	Licensee will conduct and document a disaster drill with children by 3/13/2026. Licensee will provide photo proof of the completed drill to the department by 3/13/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Renesha Askew
NAME OF LICENSING PROGRAM MANAGER:

	Jody Dye
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/06/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2026

LIC809 (FAS) - (06/04)

Page: 3 of 7

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: 03/06/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed a CPR/FA certification from National CPR Foundation which does not meet EMSA requirments. Licensee has not completed Mandated Reporter Training since 2018. lmmunization requirements per SB792 were met. Required documents have been posted.

Children’s and Staff records were reviewed and found to be in order. Facility roster is maintained, reviewed, and a copy was received. The licensee has not conducted fire and disaster drills. LPA observed a disaster drill log which has not had a documented drill since 08/13/2023. There is one crib or play yard available for infants. The licensee has no infants enrolled at this time.

The licensee provided proof of control of property. Because the licensee rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC 9151) that the licensee confirms was provided to the property owner/landlord. The licensee obtained a signed a Property Owner/Landlord Consent form (LIC 9149).

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/.

Provider is hereby reminded of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, 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 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. 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.

Continued on LIC 809-C page 3

NAME OF LICENSING PROGRAM MANAGER: Renesha Askew
NAME OF LICENSING PROGRAM ANALYST: Jody Dye
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/06/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2026

LIC809 (FAS) - (06/04)

Page: 5 of 7

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: 03/06/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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.

Licensee states is registered to receive Provider Information Notices (PINs). LPA discussed and provided Licensee with the following: child care advocates-email address: childcareadvocatesprogram@dss.ca.gov . In addition, for general questions or questions regarding licensing requirements contact the Child Care Licensing Duty Line at (619) 767-2248.

Licensee was informed of the MyChildCarePlan.org site, 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.

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.

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

See LIC809D for deficiencies cited.

Exit interview conducted and report was reviewed with the licensee SamSam Mohamed.

A notice of site visit was given and must remain posted for 30 days.

NAME OF LICENSING PROGRAM MANAGER: Renesha Askew
NAME OF LICENSING PROGRAM ANALYST: Jody Dye
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/06/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2026

LIC809 (FAS) - (06/04)

Page: 6 of 7