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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416568
Report Date: 12/04/2024
Date Signed: 12/04/2024 11:32:48 AM

Document Has Been Signed on 12/04/2024 11:32 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:KHURRAM, TAHIRAFACILITY NUMBER:
434416568
ADMINISTRATOR/
DIRECTOR:		TAHIRA KHURRAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 390-9810
CITY:SAN JOSESTATE: CAZIP CODE:
95139
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 1DATE:
12/04/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Tahira KhurramTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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At 8:35 AM, Licensing Program Analysts (LPAs) Andy Yang and Angela Luz met with Licensee, Tahira Khurram to conduct an unannounced annual random inspection. Present for this inspection were Licensee (1) Staff, (3) Children (1 infant and 2 pre-school age). The home was toured to conduct a Health and Safety Inspection. Days and hours of operation are from Monday to Friday 8:00 AM to 8:00 PM.

The home is single family home. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are living room, bedroom 2, bathroom, and backyard. The OFF LIMIT AREAS are bedroom 1, master bedroom, master bathroom, kitchen, and dining area, are inaccessible by closed and/or locked doors and visual supervision. The ISOLATION AREA is bedroom 2. Licensee has converted the garage to an accessory dwelling unit (ADU) and requested for inspection to use as on-limit. ADU has fire inspection approval from SJFD which was approved on 11/04/2024, which is in file. Licensee has provided updated facility sketch (LIC 999) indicating all rooms in the ADU as on limit, and approved building permit which was approved on 9/09/2024, which is in file. LPA inspected the ADU which consists of living room, (2) bedrooms, bathroom, and a kitchenette. The outdoor play area is free from defects or dangerous conditions and is fenced. There have been no changes from the areas previously identified as OFF LIMITS. There are ample age-appropriate toys that appear to be safe and in good condition. There are no bodies of water. All hazardous materials and toxins are kept out of the reach of children. Licensee states that any poisons are stored in in accessible area which is OFF LIMITS. LPA reminded Licensee that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes.

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SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 12/04/2024
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The home has a fully charged (2) 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The Licensee CPR and First Aid certificate is current and expires 3/13/2025. Licensee completed the Mandated Reporter Training for Child Care Providers on 7/31/2023 (expires on 7/31/2025) and a copy of the certification is on file. Licensee was reminded of Mandated Reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. A copy of the licensee’s immunization is on file. Per Licensee, there are no firearms in the home. The Licensee conducts and documents fire and disaster drills every six months. Personnel records are available for review and contain all required forms. Child’s records are available for review and contain all required forms. All REQUIRED forms are posted and visible for public review.

All cribs or play yards meet the safety standards. The cribs or play yards do not hinder entrance or exit to and from the space where infants are sleeping. The mattresses in the crib or play yards are firm and covered with a fitted sheet that is appropriate, fits tightly, and overlaps the underside of the mattresses. Each infant’s bedding is used for them only and cleaned weekly or before use by another infant. There are no loose articles and objects, bumper guards or objects hanging above or attached to the side of the cribs or play yards. Each infant under 12 months of age has an Individual Infant Sleeping Plan maintained in the file signed and dated by the infant’s authorized representative, including the infant’s sleeping position and documentation of 15 minute checks while sleeping.

Forms of discipline to be used by Licensee are redirecting and talking with the child. Licensee understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, children are treated with dignity, receive safe, healthful, and comfortable accommodations, interference with eating, intimidation, or other actions of a punitive nature.

Also, discussed with the Licensee was isolation of sick children, supervision of children, staffing ratio and capacity, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute.

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SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 12/04/2024
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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 webpage 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.

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 child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE, Tahira Khurram, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Megan's Law was checked on 10/07/2024

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SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 12/04/2024
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

No deficiency issued during today's inspection.

Updated facility sketch (LIC 999) including the ADU to be utilized as on limit is pending Licensing Program Manager's approval.

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

Exit interview conducted and report was reviewed with the Licensee, Tahira Khurram.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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