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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414724
Report Date: 08/02/2023
Date Signed: 08/02/2023 11:21:03 AM


Document Has Been Signed on 08/02/2023 11:21 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, 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: 3DATE:
08/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Tahira KhurramTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Marilou Monico conducted a Case Management Inspection in response to an alleged incident that was self reported by Licensee to Community Care Licensing (CCL) on July 17, 2023. LPA met with Licensee, Tahira Khurram, and explained the purpose of today's visit. Also present in the home were licensee's husband, licensee's adult helper, and three infants.

During the inspection, LPA interviewed licensee's helper. LPA obtained a copy of children's roster.

Due to insufficient information available at this time, the alleged incident is under investigation.

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

There were no deficiencies cited.

A NOTICE OF SITE VISIT WAS ISSUED 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: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
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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