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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629491
Report Date: 12/08/2022
Date Signed: 12/08/2022 02:25:02 PM

Document Has Been Signed on 12/08/2022 02:25 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:GHOLAMI, GHOLAM & HOSEINI, MARYAM FCCFACILITY NUMBER:
376629491
ADMINISTRATOR:GHOLAM G. & MARYAM H.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 212-3841
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
12/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Maryam HoseinTIME COMPLETED:
01:45 PM
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On 12/08/2022, at 11:45am, Licensing Program Analysts (LPAs), David Miler and Vicky Williamson conducted an announced change of location application with the licensees; Maryam Hoseini, Gholam, Gholami, adults Nazanin Najafi and Fatema Rezaee were also present in the home. The purpose of the inspection is to ensure the home is in compliance with standards established in CCR, Title 22, Division 12, Chapter 3, for Family Child Care Homes. This three-story home has 6 bedrooms, and 7 bathrooms home was toured and inspected. Fatema Rezaee provided translation from Arabic.

Licensee will utilize the Living Room, kitchen, and bathroom; all located on the second floor. Off limits areas include the unit on the first floor, unit on the second floor, and entire living area on the third floor. All separate living units are made inaccessible to children through the use of locks. The game room on the second floor is also not accessible and made inaccessible to children through the use of a lock. The fire extinguisher, smoke and carbon monoxide detectors met requirements at this time. Children’s toys and play equipment are available. The applicant has a working cell phone. Applicant stated there are no firearms, ammunition or other weapons in the home. Licensee stated there is a pool in the home. LPA observed that the pool fence has a gap. LPA was able to fit through the gap. In addition, the four gates leading to the pool are not self latching.

Applicant maintains documentation of proof of control of property for review by the Department. Mandated Reporter AB1207 training was completed on 11/07/2022. Applicant completed 8 hours of preventative health on 12/07/2022. Pediatric CPR and First Aid certifications expire on 07/13/2024. Required documents are posted. Applicant and adult residents in the home have criminal record clearances on file. Applicant was advised that any new/additional adults must be cleared prior to working or residing in home. Immunization records per SB792 were reviewed and met regulations. Applicant states she is financially secure to operate a family child care home for children and will comply with all regulations and laws governing family child care homes. Hours of operation are Monday-Friday from 12:01am to 11:59pm.
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SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: David Miller
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: GHOLAMI, GHOLAM & HOSEINI, MARYAM FCC
FACILITY NUMBER: 376629491
VISIT DATE: 12/08/2022
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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. Megan’s Law was discussed meganslaw.ca.gov. A new provider packet was provided and discussed, including: PIN 20-24-CCP Safe Sleep Regulations including Individual Infant Sleeping Plan (LIC9227) and sleeping infants shall be physically checked every 15 minute and checks shall be documented, shaken baby syndrome, lead exposure, required postings, PIN 21-02-CCLD for Guardian, prohibited items and no smoking or corporal punishment in a day care.

LPA discussed the maximum capacity for a small family child care home: four infants only (infant means any child under 24 months); or six children with no more than three infants; or, with landlord consent, eight children with no more than two infants, one child in kindergarten or elementary school and one child at least age six, including children under age 10 who live in the home.

Applicant is advised to regularly visit the Community Care Licensing WEB SITE: http://www.ccld.ca.gov/ for quarterly updates and updated regulation information. Duty Line was provided: (619) 767-2248. Southern California Child Care Advocate information was provided, and applicant was encouraged to subscribe through the CCLD website in order to be placed on an email list for updated regulation information. Advocate information was provided: (714) 703-2800 or childcareadvocatesprogram@dss.ca.gov. Applicant was reminded, per Title 22, Division 12, Chapter 3, for Family Child Care Homes, regulation 102352(f)(1) child care is provided ‘in the care giver’s own home’ and Health and Safety Code §1596.78(a) ‘Family day care home means a home that regularly provides care… in the provider’s own home’. LPA provided applicant with a copy of the regulation and Health and Safety Code
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: David Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: GHOLAMI, GHOLAM & HOSEINI, MARYAM FCC
FACILITY NUMBER: 376629491
VISIT DATE: 12/08/2022
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The following is required prior to licensing:

1. ensure that the pool is completely surrounded by a 5-foot fence with no gaps. Install self-latching gates that open away from the pool.

The following was discussed and will be provided to applicant: LIC809, LIC809C and LIC9102AN reports. LPA explained the inspection report, applicant stated she understood. An exit interview was conducted and a copy of the reports were provided to the applicant. A license for a small family child care home may be issued following a final file review and corrections highlighted in the above paragraph in regarding the pool.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: David Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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