434416568-12-20-2023-07-CC-JCRZ-CYPQ4J-20231220105024

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416568
Report Date: 12/20/2023
Date Signed: 12/20/2023 10:50:30 AM

Document Has Been Signed on 12/20/2023 10:50 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, TAHIRA		FACILITY NUMBER:	434416568
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 2	CENSUS: 0	DATE:	12/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Tahira Khurram		TIME COMPLETED:	11:20 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Janette Cruz conducted an announced prelicensing inspection with Tahira Khurram, Applicant. The purpose of today's inspection: address the Application for a Small Family Child Care Home license (Change of Location) that the Applicant submitted to the Department on December 15, 2023. The Applicant is currently licensed at 1010 September Drive, Cupertino, 95014 (Facility #434414724). Application/Record Review: LPA observed that no children were present in the home during today’s inspection. Also present during today's inspection are Ali Khurram (Applicant's husband), Fahmeeda Pervez (Licensee's mother) , Humza Ali (Applicant's adult son) and Fatima Ali (Applicant's adult daughter). Applicant stated that she, her husband and adult children are the adults residing in the home. Days and hours of operation will be Monday to Friday from 7:30 AM to 6:30 PM. The Applicant completed the Preventative Health and Safety Child Care Training on 12/06/23 and a copy of the certification is on file. The Applicant has proof of Pediatric CPR and First Aid training on 03/13/23 on file. A copy of current TB test, flu , MMR, and Tdap vaccinations for the Applicant are on file. Proof of completion of the Mandated Reporter Training for Child Care Workers (completed on 07/31/23) is on file. The Applicant owns the home and copy of grant deed verifying control of property is on file. The Applicant has child care liability insurance valid until 1/20/25 on file. All individuals subject to a criminal record review have obtained a criminal record and child abuse index clearances prior to today's inspection. The Applicant agreed to give LPA a tour of the home (indoor/outdoor) during today's inspection. Physical Plant tour: LPA observed the home is a single-story home with three (3) bedrooms, (2) bathrooms, living room, kitchen with dining area, garage and backyard. There is a working telephone in the home (cell #408-390-9810). The home is clean and orderly, with heating and ventilation for safety & comfort.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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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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: 434416568
	VISIT DATE: 12/20/2023

NARRATIVE

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LPA observed no fireplace and no wall heaters. The off-limit areas inside the home are: master's bedroom with bathroom, bedroom #1, kitchen/dining and attached garage. There are safe and age-appropriate toys, play equipment, and materials for the children in the home. The Applicant has a designated area in the home (bedroom 2) where a child(ren) can be isolated if exhibiting signs of illness. The home has at least 1 working smoke and carbon monoxide detector in the home (tested by the Applicant during today's inspection). The Applicant has one fully charged fire extinguisher (3A40BC) inside the home. The Applicant states she does not have any pets or weapons in the home. All cleaning compounds and medications are adequately stored (locked cabinets) and garage inaccessible to children. LPA reminded Applicant that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes. The Applicant has a first aid kit in the home, with sufficient emergency supplies, including a no-touch thermometer.

Kitchen tour: LPA observed the refrigerator and freezer in the home are clean. There are no sharp utensils, cleaning products, lighters/matches, or open bottles of alcohol accessible to children. The Applicant understands that any food/drink which is brought by parent(s) of day care child(ren) must be properly labeled with the child(ren) name and properly stored or refrigerated.

Bathroom tour: LPA observed the bathroom toilet and faucet are clean, safe, and operable. The shower are is free of any hazards. All shampoos, soap, medication, mouthwash, perfumes, razors, cleaning products, air fresheners, and nail polish/remover are inaccessible to the children.

Outdoor tour: LPA observed the outdoor backyard of the home is fenced, safe, and secure for the children. There are no bodies of water in the backyard. Off-limit area outdoor : None. Applicant was advised that outdoor play shall be supervised at all times.

Forms of discipline used by Applicant: talking to children and redirecting. The Applicant understands that children's personal rights should not be violated; including no corporal punishment, supervision of children, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed with the Applicant during today's inspection.

LPA reviewed with Applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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: 434416568
	VISIT DATE: 12/20/2023

NARRATIVE

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This facility plans to provide Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

LPA discussed the safe sleep regulations with Applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed [applicant, licensee, or facility representative] 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.

LPA advised Applicant that a small Family Child Care Home license will be approved upon review and approval by LPA's manager.

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

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

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