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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414724
Report Date: 07/17/2019
Date Signed: 07/17/2019 10:46:39 AM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:KHURRAM, TAHIRAFACILITY NUMBER:
434414724
ADMINISTRATOR:KHURRAM, TAHIRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 390-9810
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:14CENSUS: 7DATE:
07/17/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Tahira KhurramTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA), Marilou Monico, made an unannounced annual random inspection. LPA met with Licensee, Tahira Khurram, and explained the nature of today's visit. Also present in the home were licensee's husband, two adult helpers, and 7 daycare children including 3 infants and 4 preschool age. Days and hours of operation are Monday to Sunday from 7:30 AM to 10:00 PM. There are two adults living in the home: licensee and her husband.

LPA toured the home both indoor and outdoor. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean and orderly. There is a fully charged 3A40BC fire extinguisher, working smoke detector, functioning carbon monoxide detector, barricaded fireplace, and no bodies of water. Off limit areas in the home: master bedroom, master bathroom, bedroom #1, kitchen, furnace closet, and garage. Off limit areas outside the home: gated side yard and barricaded area of the backyard. Medications, cleaning compounds, sharp objects, and other similar items are stored out of reach of children. Per licensee, there are no weapons in the home. Five children's files and helper's files were reviewed. Licensee maintains a current children's roster and fire drill log. LPA obtained copy of children's roster. Licensee has current CPR/First Aid certifications with an expiration date of July 2020. The home has a working telephone which is (408) 390-9810.

LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporter Training) which is required training that began on January 1, 2018 and requires renewal every two years. AB 633 was discussed with Licensee. Licensing forms, Title 22 regulations, can be obtained through the internet at ww.ccld.ca.gov. Mandated Reporter Training can be accessed at www.mandatedreporterca.com. Licensee has completed the Mandated Reporter Training.

Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility.

(REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 07/17/19):
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KHURRAM, TAHIRA
FACILITY NUMBER: 434414724
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2019
Section Cited
HSC
1596.8662(b)(1)
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MANDATED REPORTER TRAINING - On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training and shall complete renewal every two years following the date on which he or she completed the initial mandated reporter training.
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Licensee states that proof of completion to be sent to Licensing by 08/16/19.
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This requirement is not met as evidenced by: LPA observed that Licensee's two adult helpers have not completed the Mandated Reporter Training. This poses a potential risk to health and safety to children 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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KHURRAM, TAHIRA
FACILITY NUMBER: 434414724
VISIT DATE: 07/17/2019
NARRATIVE
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(CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 07/17/19):

A review of staff records during today's inspection indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemption.

As a result of this inspection, deficiency was cited on the following page:



NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3