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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376628583
Report Date: 10/21/2022
Date Signed: 10/21/2022 03:29:09 PM

Document Has Been Signed on 10/21/2022 03:29 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:CHEMSI, MOUNIA FAMILY CHILD CAREFACILITY NUMBER:
376628583
ADMINISTRATOR:MOUNIA CHEMSIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 988-6622
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
10/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Mounia ChemsiTIME COMPLETED:
03:45 PM
NARRATIVE
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On 10/21/2022 Licensing Program Analyst (LPA) Edgar Campana conducted an unannounced Case Management visit for the purpose of citing deficiencies discovered during complaint investigation.

During inspection of home, LPA observed that stair case in living room was not barricaded and there were children under the age of five (5) years old present.

During review of records, it was determined that current facility roster is not being maintained.

Please refer to LIC 809-D for Type-B deficiencies cited.

An exit interview was conducted with Licensee. LPA informed Licensee that Notice of Site Visit (LIC 9213) is to be posted for thirty (30) days from today’s date. The following was provided to Licensee: LIC809, LIC9213 and appeal rights.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Edgar Campana
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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
Document Has Been Signed on 10/21/2022 03:29 PM - It Cannot Be Edited


Created By: Edgar Campana On 10/21/2022 at 12:48 PM
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: CHEMSI, MOUNIA FAMILY CHILD CARE
FACILITY NUMBER: 376628583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2022
Section Cited
CCR
102417(g)(3)

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(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
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Licensee barricaded stairs before LPA left. Licensee stated that she will be making living room off-limits in the near future, making the stair case inaccessible to children in care.
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Based on LPA observations, the staircase in the living room is not barricaded, which poses a potential health, safety or personal rights risk to persons in care.
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LPA advised Licensee to submit an LIC279A and updated LIC999 to reflect the new entrance to daycare, and revised off-limits areas of day care, and that this must be done prior to making changes in facility.
Type B
11/01/2022
Section Cited
HSC1596.841

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Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.
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Licensee stated that she will submit the facility roster to Licensing by 10/28/2022.
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This requirement is not met as a facility roster is not available for review today. This poses a potential health and safety risk to clients 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:Jason Garay
LICENSING EVALUATOR NAME:Edgar Campana
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022


LIC809 (FAS) - (06/04)
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