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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409767
Report Date: 07/30/2026
Date Signed: 07/30/2026 11:12:46 AM

Document Has Been Signed on 07/30/2026 11:12 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:KHAN, KHADIJAFACILITY NUMBER:
073409767
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 7CENSUS: 4DATE:
07/30/2026
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Khadija KhanTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 07/30/2026 at 9:00 AM Licensing Program Analyst (LPA) Mone Flores conducted an Unannounced Case Management / Licensee Initiated Inspection for a change of capacity at Khadija "Tam" Khan's Family Childcare Home. LPA met with the Licensee, Khadija Khan, and explained the purpose of today's inspection. There were two infants, one preschool aged child, and one school aged child present during today's inspection. Licensee stated there are seven children enrolled and a few families waiting for her approved capacity increase. Residing in the home are the licensee, the licensee's spouse, who are both fingerprint cleared, and Licensee's three minor children. Licensee’s home was toured for a health and safety inspection. The facility operates Monday to Friday, 8 AM - 5 PM.

The home is a two-story home that consists of four (4) bedrooms, four (4) bathrooms, a loft (located upstairs), laundry room, kitchen, dining room, family room, living room, garage, and backyard. The entrance to the day care is the front door. The inside and outside of the home were observed to be neat, clean with age-appropriate materials and toys for the children. Toxins, medications, and hazardous materials were observed to be located in inaccessible areas during today’s inspection. LPA observed the following precautions: accessible cabinets and drawers in the kitchen have safety latches and stairs located near the front door are blocked off by a safety gate and made inaccessible to children in care. Licensee stated there are no firearms or pets in the home. LPA did not observe a body of water in or around home.

ON LIMITS AREA: The family room and dining room which are the main day-care rooms, living room, bedroom 4 which is used for napping and is located downstairs, bathroom 4 which is located near bedroom 4 downstairs, and the fenced backyard not including the left and right side of the yard which requires visual supervision to ensure inaccessibility.

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Sherelle Johnson
Mone Flores
DATE: 07/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: KHAN, KHADIJA
FACILITY NUMBER: 073409767
VISIT DATE: 07/30/2026
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OFF LIMITS AREA: The entire second floor which consists of: Bedroom 1 (Master Bedroom) , Bedroom 2, Bedroom 3, the master bathroom, bathroom 2, bathroom 3, loft area, laundry room, and on the first floor only the kitchen and the garage. The yard is fully fenced and has an AC unit inaccessible by supervision.

ISOLATION AREA: The living room, away from other children in care.

The home has a fully charged 2A10BC fire extinguisher, fully stocked first aid kid, a working dual smoke/carbon monoxide detector, a working telephone, and all required forms are posted. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 07/12/2026. The licensee's CPR and First Aid certificate is current and expires on 01/31/2027. The Licensee was reminded of the responsibility as a mandated reporter and has provided proof of the required training which was conducted on 02/02/2025 and expires on 02/02/2027. LPA obtained a current facility roster. The licensee is in compliance with the immunization law. As of 07/23/2026 Contra Costa County Fire department has granted clearance for fire inspection.

Facility does provide transportation for children and the licensee understands that children cannot be left alone, unattended in parked vehicles.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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-andresources/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.

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NAME OF LICENSING PROGRAM MANAGER: Sherelle Johnson
NAME OF LICENSING PROGRAM ANALYST: Mone Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: KHAN, KHADIJA
FACILITY NUMBER: 073409767
VISIT DATE: 07/30/2026
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22- 02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

On this date, 06/19/2026, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

LPA discussed and reminded Licensee that a day care needs to be operated within the limitations and capacity of a Large Family Child Care Home with regards to ratios and that Licensee has to be present in the day care for 80% of the operation hours. All documents have been reviewed for the increase of capacity application. The Licensee was reminded that an assistant is needed with a large family child care home license, and whenever an assistant is not present, the licensee will comply with the capacity requirements for a small family child care home. LPA discussed the ratios for a large family childcare home. LPA reviewed the required documents for Assistant's files and provided the forms to keep in their file.

As of 07/30/2026, LPA recommends this home to be Licensed as a Large Family Child Care Home.

A notice of site visit was given and must remain posted for 30 consecutive days.

Exit interview conducted and report was reviewed with the Licensee, Khadija "Tam" Khan.

A copy of the report was provided to the Licensee.

NAME OF LICENSING PROGRAM MANAGER: Sherelle Johnson
NAME OF LICENSING PROGRAM ANALYST: Mone Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026
LIC809 (FAS) - (06/04)
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