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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629491
Report Date: 02/27/2023
Date Signed: 02/27/2023 12:11:00 PM

Document Has Been Signed on 02/27/2023 12:11 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:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 19CENSUS: 0DATE:
02/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Maryam Hoseini TIME COMPLETED:
12:15 PM
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On 02/27/2023 at 11:15am, Licensing Program Analyst (LPA) David Miller conducted an unannounced case management inspection for the purpose of a capacity increase from a small to a large license. LPA met with the licensee, Maryam Hoseini. There were no daycare children present. Translation was provided by licensee's daughter, Zahra Gholami from Arabic.

On 12/20/2022, Licensee submitted an application (LIC 279) requesting a capacity increase. The Fire Safety Inspection Request (STD 850) was approved for fourteen (14) children on 02/08/2023.

Licensee will utilize the Living Room, kitchen, and bathroom; all located on the second floor. Off limit 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 licensee has a working cell phone. Licensee 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 meets regulations, that the fence surrounding the pool is at least 5-feet high with no gaps, and that the gates are all self-latching and open away from the pool.

The fire extinguisher is rated 2A 10B: C. and is in the kitchen mounted on the kitchen wall. The smoke/carbon monoxide detector meets requirements and is operational. LPA observed that the home has sufficient space, toys, and equipment available for children’s use.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: David Miller
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2023
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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: GHOLAMI, GHOLAM & HOSEINI, MARYAM FCC
FACILITY NUMBER: 376629491
VISIT DATE: 02/27/2023
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Mandated Reporter AB1207 training was completed on 11/07/2022. Licensee completed 8 hours of preventative health on 12/07/2022. Pediatric CPR and First Aid certifications expire on 07/13/2024. Licensee conducted a fire drill on 01/10/2023.

The Licensee was provided with the Ratio/Capacity Worksheet for a large family childcare home. The Licensee acknowledged that if no assistant provider is present at a Large Family Child Care Home, then the Licensee shall comply with the capacity requirements for a Small Family Child Care Home. Licensee is the homeowner.

The Licensee 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 (SCCCA) information was provided. The Licensee is already enrolled in this program’s email
email list through the CCLD website, thus receives updated regulation information. Advocate information was provided: (916) 654-1541 and childcareadvocatesprogram@dss.ca.gov

A large license may be issued after a final file review. No deficiencies cited during today’s inspection on this date.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the licensee, Maryam Hoseini.

SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: David Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC809 (FAS) - (06/04)
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