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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376101096
Report Date: 10/24/2022
Date Signed: 10/24/2022 11:35:43 AM

Document Has Been Signed on 10/24/2022 11:35 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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:HAOUASH, KHETAM FAMILY CHILD CAREFACILITY NUMBER:
376101096
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
10/24/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Khetam HaouahTIME COMPLETED:
11:45 AM
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On 10/24/22 at 11:00 AM LPA Annette Sutherland conducted an unannounced case management site visit for a capacity increase. This visit is to verify that the licensee remains in substantial compliance with the health & safety standards as required by regulations governing family childcare homes. LPA met with licensee Khetam Haouash. Licensee has all appropriate forms posted. LPA confirmed with licensee that all adults residing/working in the home have criminal record/TB clearances. Applicant rents the apartment. The home appears to be large enough to comfortably accommodate 14 children. Fire clearance was received on 9/28/22. First Aid and CPR certifications was taken on (insert date). Children’s records were not reviewed, as licensee did not have any children present. Licensee has practiced fire/emergency drills with daycare children according to regulations. Las t fire drill was conducted on July 10, 2022.

The two-story home (2 bedrooms, 2 bathrooms) was toured, the following areas are used for daycare: Living room, Kitchen, Bathroom #1 and Back yard.
Off limit areas include: Entire upstairs and front yard. Stairs are barricaded.
Drawers and lower cabinets in kitchen are either latched or do not contain any hazardous items. There is an operational smoke alarm, carbon monoxide detector and fire extinguisher maintained in the home. There are adequate age appropriate toys. There are no firearms present on the premises as stated by licensee. There is a fenced pool in the apartment complex that meets title 22 regulations. Per licensee, operating hours are from 7:00 AM- 12:00 PM; 7 days a week.

Continued on LIC 809 C
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Annette Sutherland
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
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: HAOUASH, KHETAM FAMILY CHILD CARE
FACILITY NUMBER: 376101096
VISIT DATE: 10/24/2022
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LPA reviewed the following: required departmental documents, regulation highlights, community resources, capacity limitations, supervision, clearances, emergency drills, heat-related illness, child passenger law, unusual incidents, mandated reporting, Assembly Bill 633, SIDS, Safe sleep regulations, Shaken Baby Syndrome, Megan's law and Covid information. Applicant is reminded that corporal punishment, smoking, walkers, exersaucers, jumpers and bouncy seats shall never be permitted during daycare operation. Any equipment used should only be used according to the manufacturer recommendations.

For licensing regulations/updates/forms, go to webpage http://www.ccld.ca.gov

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.

No Corrections

No deficiencies are cited. No corrections are needed; a license for 14 children will be issued effective today.

The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. LPA provided notice of site visit and observed it being posted at the facility.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Annette Sutherland
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC809 (FAS) - (06/04)
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