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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100999
Report Date: 07/11/2024
Date Signed: 07/11/2024 10:03:47 AM

Document Has Been Signed on 07/11/2024 10:03 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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:ARABO, BALSAM FAMILY CHILD CAREFACILITY NUMBER:
376100999
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
07/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Balsam AraboTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
NARRATIVE
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On 7/11/2024 @ 8:45AM, Licensing Program Analysts (LPA) Nancy Diaz and Mahjoba Raofi conducted an unannounced case management inspections in reference to Mrs. Arabo's request for an increase of capacity. Mrs. Arabo was home today with her 3-year old son. Her sister, Nasma Arabo helped translate this inspection in Chaldean via telephone.

Fire clearance was received from the Santee Fire Department on 7/5/2024. A tour of the facility was conducted with Mrs. Arabo.
Mrs. Arabo maintains a combination smoke and carbon monoxide detector. It was tested today and deemed operable. Mrs. Arabo maintains a regulation-size fire extinguisher.
LPAs reviewed children's files today. Some of the files were not available for review and some were incomplete.

Type B deficiencies were cited today. Type B deficiencies if not corrected poses a potential risk to the health, safety or personal rights of children in care.

Increase of capacity to be granted upon submission of proof of corrections.
The licensee has not obtained a signed Property Owner/Landlord Consent form (LIC9149). Without this consent, the applicant understands that, once licensed, they can operate with a maximum capacity of 12 children. If property owner/landlord consent is obtained in the future, the applicant is advised that a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 14 children.

Exit interview was conducted with Mrs. Arabo. LPA reviewed and provided a copy of this report to Mrs. Arabo. Notice of site visit and appeal rights were also given. Notice of site visit must be posted for 30 days.
SUPERVISORS NAME: Joelle Redding
LICENSING EVALUATOR NAME: Nancy Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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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Document Has Been Signed on 07/11/2024 10:03 AM - It Cannot Be Edited


Created By: Nancy Diaz On 07/11/2024 at 09:35 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: ARABO, BALSAM FAMILY CHILD CARE
FACILITY NUMBER: 376100999

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2024
Section Cited
CCR
102425(J)

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INFANT SAFE SLEEP. The provider shall supervise infants while they are sleeping and adhere to the following requirements:
(1) The provider shall physically check on the infant every 15 minutes.
THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY:
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LPA provided a sample form of nap log. Mrs. Arabo stated that she will document the 15-minute checks when children under two nap. Mrs. Arabo will submit copies of the 15-minute nap logs to the department no later than 7/18/24.
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Based on record review, Mrs. Arabo currently has two children under age two. She did not maintain 15-minute logs for those children in care.
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Type B
07/18/2024
Section Cited
CCR102417(g)(8)

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OPERATION OF A FAMILY CHILD CARE HOME. Each family child care home shall have a current roster of children...

THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY:
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LPA provided Mrs. Arabo a blank LIC 9040. She stated that she will update form and submit a copy to the department no later than 7/18/2024.
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Based on record review, Mrs. Arabo did not maintain a current children's roster (form LIC 90400.
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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:Joelle Redding
LICENSING EVALUATOR NAME:Nancy Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2024 10:03 AM - It Cannot Be Edited


Created By: Nancy Diaz On 07/11/2024 at 09:42 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: ARABO, BALSAM FAMILY CHILD CARE
FACILITY NUMBER: 376100999

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2024
Section Cited
CCR
102417(g)(7)

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OPERATION OF A FAMILY CHILD CARE HOME. An emergency information card shall be maintained for each child and shall include the child's full name,...
THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY:
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Mrs. Arabo stated that she will provide the form to parents for completion and submit copies to the department no later than 7/18/2024.
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Based on record review, Mrs. Arabo did not maintain completed Emergency Identification form (LIC 700) for 4 children.
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Type B
07/18/2024
Section Cited
CCR102418(g)

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IMMUNIZATIONS
The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such...

THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY:
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Mrs. Arabo stated that she will obtain immunization information and complete Blue cards and submit copies to the department no later than 7/18/2024.
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Based on record review, Mrs. Arabo did not maintain immunization information on Blue cards.
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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:Joelle Redding
LICENSING EVALUATOR NAME:Nancy Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024


LIC809 (FAS) - (06/04)
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