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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414724
Report Date: 04/14/2022
Date Signed: 04/14/2022 12:12:10 PM


Document Has Been Signed on 04/14/2022 12:12 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, 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: 0DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Tahira KhurramTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA), Marilou Monico, conducted an unannounced Required - 1 Year inspection. LPA met with Licensee, Tahira Khurram, and explained the purpose of today's visit. Also present in the home was licensee's husband. There were no daycare children present. Licensee states that she closed her daycare from March 2020 to September 2021, reopened for four days in September 2021 then decided to close temporarily due to personal reason. Licensee states she wanted to keep her license on active status. LPA observed all required posted materials. Days and hours of operation for the facility are Monday – Sunday, 7:00 AM- 10:00 PM. There are no active waivers or exceptions for this facility. Licensee states that the adults residing in the home are herself and her husband.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Indoor licensed areas of the facility were inspected by LPA today and observed to be clean, orderly, and safe for the day care children. LPA observed a fully charged 3A40BC fire extinguisher, barricaded fireplace, and functioning smoke and carbon monoxide detectors. Licensee states that there are no weapons or firearms in the home. Off limit areas in the home: master bedroom, master bathroom, bedroom #1, kitchen, furnace closet, and garage. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as table, chairs/couches are in good condition and safe for children. The floors were clean and free of tripping hazards. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (408) 390-9810.

Continuation on next pages:
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KHURRAM, TAHIRA
FACILITY NUMBER: 434414724
VISIT DATE: 04/14/2022
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The outdoor licensed areas of the home were inspected. The home is surrounded by fence. Off limit areas outside the home: gated side yard and barricaded area of the backyard . There were no bodies of water observed.

Licensee has Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and statement declining the influenza vaccine. The Licensee has Mandated Reporter Training that expires on September 7, 2023. Licensee's CPR/First-Aid expires on March 1, 2023. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years.

This facility provides Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.



LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Supervision of children was discussed with the Licensee and she understands that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Continuation on next page:
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 2 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: 04/14/2022
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process


Exit interview conducted and report was reviewed with the Licensee, Tahira Khurram.

As a result of todays inspection, there were no deficiencies cited.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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