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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627808
Report Date: 12/21/2021
Date Signed: 12/21/2021 02:32:23 PM

Document Has Been Signed on 12/21/2021 02:32 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:MOHAMED, MARIAM FAMILY CHILD CAREFACILITY NUMBER:
376627808
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
12/21/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Miriam MohamedTIME COMPLETED:
02:45 PM
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On 12/21/21 at 1:00 PM LPA Adrian Mangina conducted a Case Management/Increase in capacity inspection of home with Licensee, Mariam Mohamed. The purpose of the visit is to ensure that the home is in compliance with standards established in CCR, Title 22, Division 12, Chapter 3. Also in the home was Licensee’s husband and Assistant Mohamoud Kassim and four minor children. There were no children in care. Proper supervision and ratios were observed. Licensee’s owns the home and has provided HOA bill and payments request from Bank as proof of ownership.

The three-Bedroom two-bathroom, single level home, was toured and inspected to ensure a safe and healthful environment for children. The 2A10BC fire extinguisher, smoke detector and carbon monoxide detector are operational. Licensee states that there are no weapons in the home. There are no bodies of water on the premises. The following areas are used for the childcare: Kitchen, living room, bathroom #1. Off limit areas include: master bedroom, master bathroom, bedroom #1 and bedroom #2. Inaccessible areas are kept inaccessible through the use of doorknob covers, locks, and latches. The 2A10BC fire extinguisher located in the kitchen and the smoke detector/ carbon monoxide detector located in living room meet requirements and are all operational. All hazardous items were latched/locked and secured out of reach of children. All poisons, cleaners, and hazardous items are inaccessible to children. Electrical outlets are covered, and window cords are kept out of reach.

There are sufficient and appropriate toys and equipment available in the home and backyard for children’s use. . There is a storage shed in the back yard which is kept locked with a padlock. The backyard is fenced, but there is a trampoline in the back yard which Licensee states is used for children in care with direct supervision. Licensee advised that it may be safer to exclude children in care from using the trampoline. Licensee was reminded that if children in care are allowed to use the trampoline that visual supervision is required at all times when children are outside. Storage area and exit gates in backyard are all kept locked.
(continued on LIC809 page 2)
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2021
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 2
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: MOHAMED, MARIAM FAMILY CHILD CARE
FACILITY NUMBER: 376627808
VISIT DATE: 12/21/2021
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(LIC809 page 2)

Licensee’s CPR and First aid certifications are valid through 8/22/2022. Staff immunization requirements per SB792 were met. Applicant and staff have the required immunizations. Applicant states that there are no weapons in the home Licensee’s Mandated Reporter Training AB 1207 expires 10/8/2022 and assistant, husband Mohamoud Kassim’s, expires 10/13/2023. Licensee’s and Assistant’s CPR and First aid certifications are valid through 8/2022. Assistant completed Preventative Health training on 11/4/2018.

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. Applicant advised any new/additional adults must be cleared prior to working or residing in home. Any minor upon his/her 18th birthday must be fingerprinted within 30 days. Fire clearance was approved on 12/20/21.

Per applicant operating hours are from 6:00 AM – 5:00 AM, Monday - Sunday. LPA reviewed information on ratios and capacity, child abuse reporting, children’s records, immunizations, adults living or working in the home, car seat law, shaken baby syndrome, SIDS, safe sleep practices, effects of lead poisoning, and the YMCA Resource Center. Applicant was reminded that corporal punishment, smoking, walkers, exersaucers, jumpers, and bouncy seats 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.

The facility is in substantial compliance and no deficiencies are cited at this time. A large license is recommended and may be issued after a thorough file review.

An exit interview was conducted with applicant. A copy of this report (LIC809) has been provided to the Licensee. Licensee’s signature is acknowledgement of receipt. LIC9213 Notice of Site visit provided, which must be posted for 30 days and a copy of this report to be kept in facility file for 3 years.
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC809 (FAS) - (06/04)
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