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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414724
Report Date: 10/06/2023
Date Signed: 10/06/2023 01:49:21 PM


Document Has Been Signed on 10/06/2023 01:49 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: 3DATE:
10/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Tahira KhurramTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Marilou Monico conducted a Case Management Inspection. LPA met with Licensee, Tahira Khurram, and explained the purpose of today's visit. An initial Case Management Inspection was conducted on August 2, 2023 regarding alleged incident that was self reported by Licensee to Community Care Licensing (CCL) on July 17, 2023. Also present in the home were licensee's adult assistant, licensee's mom who is visiting from outside the country, and three daycare children including two infants and one preschool age. LPA advised licensee that visitors who stay in the home for 30 days or more are required to obtain fingerprint clearances.

Based on police report, doctor's report, and interviews, there is no preponderance of evidence to prove that a child's personal rights were violated or there was lack of supervision.

LPA reminded licensee 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.

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

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

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: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
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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