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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376101651
Report Date: 08/31/2023
Date Signed: 08/31/2023 11:31:22 AM

Document Has Been Signed on 08/31/2023 11:31 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:ADIL, ZARGHONA FAMILY CHILD CAREFACILITY NUMBER:
376101651
ADMINISTRATOR:ZARGHONA ADILFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 558-9791
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 0DATE:
08/31/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Zarghona Adil and Mohammad Esmail AdilTIME COMPLETED:
11:45 AM
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On 08/31/2023 at 10:15am, Licensing Program Analyst (LPA), Selina Siao conducted a change of location inspection with applicant and her husband Mohammad E Adil (translator in Dairi). The 3 bedroom, 2 bath one stories house was toured and inspected to ensure an environment safe for the care and supervision of children. The home has a fully charged fire extinguisher size 4A60BC, smoke and carbon monoxide detector that meet requirements and are operational. All hazardous items were latched/locked and secured out of reach of children. The home does not have any bodies of water. Applicant stated that the home doesn't have any weapon. Applicant has an EMSA approved pediatric CPR and First Aid card that are current due to expire on December 17, 2023 and applicant is exempt from taking the mandated child abuse training at this time as it is not available in her native Dairi language. A review of the application and records on this date indicates that applicant and her husband are the current adult residents at the home with the require TB clearances, caregiver background checks and child abuse clearances. Applicant and her husband have the required TDAP and measles immunization.

Applicant provided proof of control of property. Because the applicant rents the home, proof of landlord notification is required. LPA Siao obtained the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

Applicant will be using the following areas for childcare: living room, bathroom and bedroom #1. Off limit areas includes: kitchen, master bedroom, bathroom, laundry room and storage room that is at a detached building. The off limit areas have safety latches or gates to prevent children's access. Outdoor area will be the fenced enclosed front yard area and visual supervision is required when children are outside.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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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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: ADIL, ZARGHONA FAMILY CHILD CARE
FACILITY NUMBER: 376101651
VISIT DATE: 08/31/2023
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LPA reviewed the facility's children's records and all forms are in ordered including the facility roster and fire drill log.

Licensee was reminded that corporal punishment, smoking, baby walkers, exersaucers, bouncy seats and baby jumpers are not allowed in day care. The ABC’S of Safe Sleep: Sleep is Safest: Alone, on their Back in an empty Crib on a firm mattress.

LPA discussed the safe sleep regulations with licensee and her husband and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/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.

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

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.

Licensee shall comply with all regulations and laws governing family childcare homes and be financially secure to operate a family childcare home for children.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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: ADIL, ZARGHONA FAMILY CHILD CARE
FACILITY NUMBER: 376101651
VISIT DATE: 08/31/2023
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

All unusual incident reports shall be submitted to Licensing office via email at SDIncidentReports@dss.ca.gov or via fax at (619)767-2203.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

The following correction is needed prior to granting a license:

  • Applicant shall submit a video of the home to show that her and her family have moved into this home.

Exit interview conducted and report was reviewed with the licensee and her husband Mohammad Esmail Adil.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Selina Siao
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC809 (FAS) - (06/04)
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