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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100463
Report Date: 08/16/2021
Date Signed: 08/16/2021 11:47:19 AM

Document Has Been Signed on 08/16/2021 11:47 AM - It Cannot Be Edited

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:KHADEM HOSSEIN, RAHIMA FAMILY CHILD CAREFACILITY NUMBER:
376100463
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
08/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rahima Khdem HosseinTIME COMPLETED:
12:00 PM
NARRATIVE
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On 8/16/21, Licensing Program Analyst (LPA) Adrian Mangina conducted an unannounced Annual inspection with the Licensee. Upon arrival, LPA met with Licensee, Rahima Khadem Hossein. The one-story first floor apartment was toured and inspected to ensure an environment safe for the care and supervision of children. Also present in the home were licensee’s own two minor children. There are currently no children in care. Proper supervision and ratios were observed. The 2A10BC fire extinguisher and carbon monoxide detector, both located in the kitchen meet requirements and are operational. The smoke detector located in the hall is non-operational. at 10:00 AM LPA observed hazardous items located in kitchen drawers (grater) and cabinets, (medication) in the back patio (detergents and cleaners) and under the bathroom sink (cleaning supplies). LPA reminded Licensee to keep hazardous items secured out of reach of children when children are in care. There are no bodies of water on the property. 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’s First Aid and CPR certifications expire on 2/20/2022. Licensee and staff meet immunization requirements. Mandated Reporter Training was waived due to Licensee’s first language is not English. LPA did not review children’s records as there are no children in care. Licensee was advised to complete LIC9040 child roster and child files when children are in care. Licensee had no record of disaster drills. Licensee advised to conduct disaster drills every six months when children in care.

Licensee has provided adequate space for the children to eat, sleep and play within the home. Areas used for child care include: kitchen, living room and bathroom. Off limits areas include: bedroom and are made inaccessible through use latches and door knob covers. There is no fireplace in the home. There is a working phone at the facility. The licensee has sufficient safe age appropriate, safe, toys and equipment available. The home has a fully fenced back patio available for outdoor activities.

Continued on LIC809 page 2
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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 3
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: KHADEM HOSSEIN, RAHIMA FAMILY CHILD CARE
FACILITY NUMBER: 376100463
VISIT DATE: 08/16/2021
NARRATIVE
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LIC809 page 2

Provider is hereby reminded of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, ensure that all adults living or working in the home have criminal background clearances associated to the facility, 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 Mangina reviewed Covid-19 guidelines with Licensee and provided Covid-19 resources. LPA Mangina directed Licensee to website: https://www.cdss.ca.gov/inforesources/community-care-licensing to receive important updates and information.

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.

The following Type B deficiency is being cited: Operation of a family child care home section 102417(g)(1) (See LIC 809D dated 8/16/21)

An exit interview was conducted with the Licensee. The Licensee was provided a copy of their appeal rights (LIC 9058) along with a copy of this the report (LIC809) their signature on this form acknowledges receipt of these rights. LPA observed LIC 9213 (Notice of Site visit) was posted during today's visit. Notice of Site Visit must remain posted for 30 days.
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/16/2021 11:47 AM - It Cannot Be Edited


Created By: Adrian L Mangina On 08/16/2021 at 11:26 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: KHADEM HOSSEIN, RAHIMA FAMILY CHILD CARE
FACILITY NUMBER: 376100463

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2021
Section Cited
CCR
102417(g)(1)

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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... the home shall contain... smoke detector device which meets standards established by the State Fire Marshal.
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Licensee stated that she will replace the smoke alarm no later than 8/30/21 and will call LPA when new smoke alarm is installed.
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THis requirement was not met as evidenced by:

Licensee tested smoke alarm which does not work. 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:Renesha Pack
LICENSING EVALUATOR NAME:Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2021


LIC809 (FAS) - (06/04)
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