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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434416568
Report Date: 11/07/2024
Date Signed: 11/12/2024 09:11:17 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2024 and conducted by Evaluator Anna Morales
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20241007090219
FACILITY NAME:KHURRAM, TAHIRAFACILITY NUMBER:
434416568
ADMINISTRATOR:TAHIRA KHURRAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 390-9810
CITY:SAN JOSESTATE: CAZIP CODE:
95139
CAPACITY:14CENSUS: 6DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Tahira KhurramTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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1. Day-care assistant interfered with infants feeding plan
2. Licensee does not ensure adequate supervision is provided resulting in children playing with unsafe objects while in care
INVESTIGATION FINDINGS:
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 Licensing Program Analyst (LPA)Anna Morales conducted a Subsequent Complaint visit to deliver the findings for the above allegations and was greeted by Licensee Tahira Khurram.
Based on the interviews conducted on 10/15/28 and on 10/28/24, a verbal agreement was made between the Licensee and with one of the parent's (P1) regarding Child's(C1)feeding plan. On 9/20/24, the verbal agreement was not followed and Child's(C1's) feeding plan was not met.
Staff stated that on occasion, children were allowed to play with objects such as plastic disposable gloves.
Based on interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegations is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12 is being cited on the next page. Licensee/Director was informed that failure to correct the deficiencies may result in civil penalties.
Exit Interview was conducted with Licensee Tahira Khurram. Appeal Rights were given.
Notice of site visit was given and must remain posted for 30 Days
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 07-CC-20241007090219
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KHURRAM, TAHIRA
FACILITY NUMBER: 434416568
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
102423(a)(2)
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Personal Rights:102423(a)(2):
a)Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following:
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Director stated that she will submit a plan to ensure that the children's feeding plans are being met and children will play with toys that are safe and will submit by the POC plan.
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2)To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.
This requirement was not met as evidenced by: Based on interviews and observation, a verbal agreement was made between the Licensee and with (P1) regarding (C1) feeding plan which was not followed on 10/3/24,and the Licensee allowed children to play with plastic gloves in the day care which is not in accordance with the manufacturer's instructions,This poses a potential health and safety risk 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.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
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