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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416813
Report Date: 01/06/2026
Date Signed: 01/06/2026 11:40:29 AM

Document Has Been Signed on 01/06/2026 11:40 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:KHANALI, SHABNAMFACILITY NUMBER:
434416813
ADMINISTRATOR/
DIRECTOR:		SHABNAM, KHANALIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 434-4405
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 3DATE:
01/06/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Shabnam KhanaliTIME VISIT/
INSPECTION COMPLETED:
11:49 AM
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On 01/06/26, Licensing Program Analyst (LPA) Jaime Gonzales conducted an unannounced annual random inspection. LPA was greeted and granted access to the home by Licensee, Shabnam Khanali. Upon arrival there were three infants. There were no other individuals in the home during the time of the inspection.

The home was toured to conduct a Health and Safety Inspection. LPA observed all required postings in the daycare room that is next to the living room. Days and hours of operation are from Monday- Friday 7:45AM-5:30PM. The ages of the children to be served are 4 months- 4 years old. The home is neat and clean with heating and ventilation for safety and comfort. The off-limit areas include: Garage, dining room, master bedroom, master bathroom, kitchen, and left side of the yard when facing the home. Off-limit areas are inaccessible by closed and/or locked doors and with visual supervision. Licensee uses the second day care room as an isolation area for sick children. Licensee stated that the backyard space is not currently being used due to the rain and will bring the children out when it stops raining in February or March. There are ample age-appropriate toys that appear to be safe and in good condition. Bathroom used by children was observed to be clean and in good operating condition.

Licensee states poisons are kept under the sink in the off-limit kitchen area. The home has two fully charged (2A10BC) fire extinguishers. LPA observed a operable smoke detector/carbon monoxide detector. Licensee confirmed she has a working telephone. The Licensee CPR and First Aid certificate is current and expires on 03/2027. A copy of the licensee’s immunization is on file. The Licensee conducts and documents fire and disaster drills at least every six months. The licensee has valid Mandated reporter training on file and it expires on 02/25/27. LPA reminded Licensee that sleep sacks, baby walkers, and similar items are not allowed in Family Child Care Homes. Licensee has valid day care insurance.

Child’s records are available for review and contain all required forms including the documentation of 15-min sleep log. LPA completed record reviews for infants enrolled and they are all over one years old. LPA observed four play yards with an extra mattress on top of the original mattress that comes standard with the play yards.

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NAME OF LICENSING PROGRAM MANAGER: Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST: Jaime Gonzales
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2026
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KHANALI, SHABNAM
FACILITY NUMBER: 434416813
VISIT DATE: 01/06/2026
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Licensee removed the extra mattresses and placed the fitted sheets on top of the original mattresses to the play yard. Licensee understands the infant sleep regulation and that younger infants that are not ready to physically sleep on a mat should be sleeping in a play yard or crib.

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, interference with eating, sleeping, intimidation, or other actions of a punitive nature. Children are treated with dignity, and receive safe, healthful, and comfortable accommodations.

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 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 22-02CCP. 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms.To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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NAME OF LICENSING PROGRAM MANAGER: Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST: Jaime Gonzales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KHANALI, SHABNAM
FACILITY NUMBER: 434416813
VISIT DATE: 01/06/2026
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During the exit interview, the LICENSEE, Shabnam Khanali confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.

During today’s inspection a deficiency was cited, and further details are on the 809-D Page.

Appeal rights provided.

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

Exit interview conducted and report was reviewed with the licensee, Shabnam Khanali.

NAME OF LICENSING PROGRAM MANAGER: Deanna Villagrana
NAME OF LICENSING PROGRAM ANALYST: Jaime Gonzales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/06/2026 11:40 AM - It Cannot Be Edited


Created By: Jaime Gonzales On 01/06/2026 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: KHANALI, SHABNAM
FACILITY NUMBER: 434416813

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(a)(4)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (4) Mattresses shall be made specifically for the size crib or play yard in which they are placed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above today as LPA observed four play yards with an extra mattress on top of the original mattress that comes standard with the play yards which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2026
Plan of Correction
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Licensee removed the extra mattresses and placed the fitted sheets on top of the original mattresses to the play yard during the time of inspection and the infant sleep regulation was reviewed with the licensee and a copy was left at the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Deanna Villagrana
NAME OF LICENSING PROGRAM MANAGER:
Jaime Gonzales
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2026


LIC809 (FAS) - (06/04)
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