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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495550
Report Date: 02/24/2025
Date Signed: 02/24/2025 01:15:34 PM

Document Has Been Signed on 02/24/2025 01:15 PM - 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:KHAIRZADA FAMILY CHILD CAREFACILITY NUMBER:
197495550
ADMINISTRATOR/
DIRECTOR:		MAHMOODA KHAIRZADAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 678-3729
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
02/24/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Mahmooda KhairzadaTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On February 24, 2025, Licensing Program Analyst (LPA) V. Wheatley conducted an announced inspection with applicant, Mahmooda Khairzada for the purpose of a pre-licensing inspection. The purpose of this inspection is for a new license to ensure the standards for a Family Child Care Home are being met in accordance to California Tittle 22 Regulations and California Health and Safety Codes. LPA inspected the indoors and outside of home.

The applicant is applying for a large family childcare license with a maximum capacity of 14. The applicant is owns the property which means the applicant qualifies for capacity 14.

Per the application, currently, the ages the applicant wishes to provide services for children 3 months old to school age with the hours of Monday through Friday 6am to 5pm and open nighttime. Applicant was informed that any changes to ages, hours and days of operation shall be submitted to the department for approval prior to initiation of changes.

The home is three bedroom and two bathroom house. The care will be provided in the living room, one bedroom, attached converted garage (ADU) and backyard. The other two bedrooms are off-limits and will remain inaccessible. There is a lock on the bedroom door. LPA observed several toys and equipment. LPA observed all electrical outlets were covered and will remain inaccessible. The home has central heating and air conditioning. The kitchen is off limits with child proof gates. LPA observed a lock on the cabinet under the sink. All detergents and chemicals will remain inaccessible. LPA observed working smoke detector, carbon monoxide detector, and charged fire extinguisher. cots for napping, The applicant understands the children must be supervised at all times.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Veronica Wheatley
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KHAIRZADA FAMILY CHILD CARE
FACILITY NUMBER: 197495550
VISIT DATE: 02/24/2025
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LPA inspected the large backyard which is fenced. The yard has artificial grass however there is a rear section that needs to be cleaned before the children can play outside. There are two sections that need to be inaccessible, one behind the storage shed and one on the side of home. Also, there is a small pipe that near the covered patio which needs to be inaccessible or barricaded. The yard will not be used until it is safe for children. LPA also observed a covered patio which will be used for the children outside.

LPA observed a converted one car garage which is now an ADU. Applicant would like to use this area for the children however all the children (large capacity) will not be allowed in this area all at the same time. LPA did not observe a fully stocked first aid kit.

According to the applicant there are no pets, no firearms and no bodies of water.

LPA reviewed the applicant's CPR/first aid which expires 11/2025 and mandated reporter training which expires 7/2026. Parent board is posted on front porch with required forms.

The following items are pending and required to in order to be licensed:
* Backyard cleaned rear yard-remove loose bricks, fertilizer, etc.
* Backyard secure side fence
* Backyard secure fence behind storage shed
* Patio-small pipes make inaccessible to the children.
* Fully stocked first aid kit.

A photograph of the yard will be emailed for approval prior to use.

Exit interview conducted, and report was reviewed with the applicant. A copy of the report provided to applicant.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Veronica Wheatley
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KHAIRZADA FAMILY CHILD CARE
FACILITY NUMBER: 197495550
VISIT DATE: 02/24/2025
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The following was discussed with the applicant:
Applicant was made aware of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on childcare licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541
Email Address: childcareadvocatesprogram@dss.ca.gov

Immunizations: Commencing September 1, 2016, SB 792, prohibits a person from being employed or volunteering at a childcare facility or family day care if he or she has not been immunized against influenza, pertussis and measles. LPA discussed the influenza waiver during the inspection.
Mandated Reporter Training: Beginning on January 1, 2018, AB 1207, requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. Website: www.mandatedreporterca.com. Licensee was reminded of their responsibility to report suspected child abuse.

Applicant was made reminded that it is the licensee’s, as well as anyone who assists in providing care responsibility to know the regulations. Applicant was also encouraged to read the P.I.N.S. and Child Care quarterly updates every season as they come out to stay informed of any changes or updates to statutes and regulations.

Applicant was advised that regulation prohibits the smoking of tobacco in a private residence licensed as a family childcare home during the hours of operation.



Applicant was made aware that state law prohibits baby walkers, bouncy seats, exer-saucers and any other items that fall into that category. Applicant was also reminded that only children who are eating may be in highchairs and that car seats are utilized only for transportation.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Veronica Wheatley
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KHAIRZADA FAMILY CHILD CARE
FACILITY NUMBER: 197495550
VISIT DATE: 02/24/2025
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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 discussed Safe Sleep Regulations with licensee. Cribs and play yards will be kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider will physically check on sleeping infants every fifteen minutes and document any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Individual Infant Sleeping Plan (LIC 9227) is required to be kept in file for each infant up to 12 months of age. Infants up to 12 months of age are required to be placed on their backs for sleeping.



LPA also informed applicant 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.

The applicant was informed regarding 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

SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Veronica Wheatley
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KHAIRZADA FAMILY CHILD CARE
FACILITY NUMBER: 197495550
VISIT DATE: 02/24/2025
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*Applicant was also informed that the provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome.
*Applicant was reminded that all adults 18 and over living or working in the home, 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.
*In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license. A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.
*Annual fees must be paid promptly and by the due date or a late fee shall be assessed, and/or the License shall be terminated. (If paying by check please make sure to write facility number on check to ensure that payment is applied to your facility number)
*The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries should be replaced.
*Changes should be reported the to the Department as soon as they occur such as construction and remodeling, telephone number changes and/or if you move from home.

*Reporting requirements: Applicant must report any unusual incident or injuries to the Child Care Regional office by telephone within 24 hours and in writing within 7 days. Applicant was provided with LIC 624 as a reference.
*Fire and safety drills must be performed every six months and documented for review by the Department.
*All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

*LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Veronica Wheatley
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KHAIRZADA FAMILY CHILD CARE
FACILITY NUMBER: 197495550
VISIT DATE: 02/24/2025
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Mandatory Forms for the children’s files and provider’s files were discussed. Applicant was referred to LIC 311D: Records To Keep in Your Family Child Care.

FORMS TO BE POSTED


LIC203 Facility License
LIC 610A Emergency Disaster Plan
LIC 9148 Earthquake Preparedness Checklist
PUB394 Notification of Parents Rights Poster
Children’s Records Requirements:
LIC 700 Identification and Emergency Information
LIC 701 Child's Health History
LIC 627 Consent for Emergency Medical Treatment
LIC 282 Affidavit Regarding Liability Insurance
LIC 9150 Parent Notification Additional Children in Care
LIC 9166 Consent/Verification for Nebulizer Care (when required)
CDPH 286 (Immunization Blue Card) with Immunization record
PUB 72- Family Child Care Consumer Guide
LIC613A -Personal Rights
LIC 995A Notification of Parent’s Rights
LIC 995E Caregiver Background Check Process
LIC 9212 Family Child Care Consumer Awareness Information
PM 286 California School Immunization Record (blue card)http://www.dhs.ca.gov/publications/forms/immunization.htm
Facility Records:
LIC 624B Unusual Incident/Injury Report (only when necessary)
LIC 9040 Child Care Facility Roster
LIC 9052 Employee Rights
LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
LIC 9149 Landlord Consent Form, if you plan to care for more than 6.
LIC 9151 Property Owner/Landlord Notification Form
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Veronica Wheatley
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC809 (FAS) - (06/04)
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