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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100700
Report Date: 05/19/2021
Date Signed: 05/19/2021 03:14:19 PM

Document Has Been Signed on 05/19/2021 03:14 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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:SHAMOON, WARDYAH FAMILY CHILD CAREFACILITY NUMBER:
376100700
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/19/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Wardyah ShamoonTIME COMPLETED:
03:20 PM
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On 5/19/2021 at 3:00PM, Licensing Program Analyst(LPA) Nancy Diaz conducted an announced follow-up Pre-Licensing inspection for a change of location with the applicant, Wardyah Shamoon. Due to COVID-19 pandemic restrictions, this inspection was completed virtually via Facetime. Applicant's daughter, Maryam was also present and helped translate in Qaldian.

The following corrections were observed/received:

- Applicant submitted an updated LIC279B.
- Applicant made bedrooms #3 and #4 inaccessible to children via door knob covers.
- Applicant remove tires, adult bikes, lumber, wooden pile and other debris from the backyard and made it inaccessible to children.
- Applicant posted required froms (LIC 610A, Parents Rights, LIC 999A, Car seat law) and COVID-19 information.

A license for a small family child care is issued effective today, May 19, 2021.

The maximum capacity for a small family child care home: 4 infants only (infants mean any children under 24 months); or 6 children with no more than 3 infants; or (with landlord consent) 8 children with no more than 2 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.

An exit interview was conducted with the applicant. Appeal Rights (LIC9058) will be sent along with the report (LIC809) via e-mail to the Applicant. Applicant will confirm receipt of this report via e-mail and the reply of confirmation will serve as the signature acknowledging these rights. The Notice of Site Visit (LIC9213) must remain posted for 30 days.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Nancy Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2021
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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