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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195700363
Report Date: 09/11/2024
Date Signed: 09/11/2024 10:16:37 AM

Document Has Been Signed on 09/11/2024 10:16 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:KURUCULASURIYA FAMILY CHILD CAREFACILITY NUMBER:
195700363
ADMINISTRATOR/
DIRECTOR:		DINUSHI KURUCULASURIYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 825-3123
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:44 AM
MET WITH:Dinushi KuruculasriyaTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Tatiana Bickham conducted an announced pre-licensing inspection for a large family child care at the above facility on 9/11/2024 at 8:44 AM. LPA met with Applicant Dinushi Kuruculasriya, who guided LPA on a tour of the facility. There was 1 child present when LPA arrived (Applicants son). Per Applicant, hours of operation will be Monday through Friday, 7:30 AM to 5:30 PM. Applicant states they will provide care for children 2 to 5 years of age.

This is a single home consisting of 4 bedrooms, 2 bathrooms, kitchen, dining room, living room, laundry room backyard, and attached garage. The home was inspected for safety, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.

Areas used by children include: Living room, dining room, bedroom #1 (first bedroom in the hallway on the right) bathroom adjacent to the day care room, and part of the backyard. Areas off limits include: 3 bedrooms, ensuite bathroom, kitchen,laundry room, part of the backyard, and attached garage. Off limit areas are made inaccessible by door lock and gate. Knives, other sharp utensils, and cleaning products are in the off limits area of the kitchen and laundry room.

The home is clean and orderly, there are outlet covers throughout the home. Smoke/carbon monoxide detector was observed, but was unable to be tested.

Applicant has completed the required health and safety training, the Pediatric First Aid and CPR. Applicant has proof of immunization against pertussis and measles, and declination letters for influenza on file. Proof of Mandated Reporter Training was also provided.
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SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KURUCULASURIYA FAMILY CHILD CARE
FACILITY NUMBER: 195700363
VISIT DATE: 09/11/2024
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Applicant will not provide food for the children, only snacks will be provided. Applicant will have parents prepare lunch for the children. LPA reminded Applicant that food brought from home should be labeled with the child's name and properly refrigerated. LPA observed age-appropriate toys and learning materials. The required (2A10BC) fire extinguisher was observed in the bedroom and was purchased in August 2024. Per Applicant, there are no weapons or firearms in the facility.

Per Applicant, the children will use the backyard for outdoor play. The outdoor play area was observed to be fenced. LPA did not observe any objects that could be hazardous to children in care. There is a pond located in the back yard with a gate that was measured at 4ft. LPA informed applicant the fence for the pond must 5ft high and no opening larger than 1 inch.

The isolation area for a sick children waiting to be picked up will be in the dining area, away from other children. 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.



The Applicant provided proof of control of property. The applicant owns the property.

Licensee 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, 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 informed Applicant any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Fire and safety drills must be performed every six months and documented for review by the Department and smoking tobacco is not allowed in a home that is licensed as a family day care home, and in those areas of the family day care home where children are present.

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.
Page 2.
SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KURUCULASURIYA FAMILY CHILD CARE
FACILITY NUMBER: 195700363
VISIT DATE: 09/11/2024
NARRATIVE
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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.

The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, 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.

CHILDREN'S RECORDS REQUIREMENTS:
• LIC 700 Identification and Emergency Information
• LIC 627 Consent for Emergency Medical Treatment
• LIC 282 Affidavit Regarding Liability Insurance
• LIC 9150 Parent Notification Additional Children in Care
• LIC 9927 Individual Infant Sleeping Plan
• LIC 995A Notification of Parent’s Rights
• Immunization Record

FACILITY RECORDS:
• LIC 624B Unusual Incident/Injury Report
• LIC 9040 Child Care Facility Roster
• LIC 9052 Employee Rights,
• LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
• LIC 9149 Property Owner/Landlord Consent Form
• LIC 9151 Property Owner/Landlord Notification Form
• Proof of current pediatric CPR and First Aid Certificates
• Copy of your deed or lease/rental agreement
• Documentation of Fire and Disaster drills
• Proof of immunizations against pertussis (TDAP), measles (MMR), and influenza
• Mandated Reporter certificate – www.mandatedreporterca.com– must be renewed every two (2) years

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SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KURUCULASURIYA FAMILY CHILD CARE
FACILITY NUMBER: 195700363
VISIT DATE: 09/11/2024
NARRATIVE
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FORMS TO BE POSTED
• LIC203 Facility License
• LIC 610A Emergency Disaster Plan
• LIC 9148 Earthquake Preparedness Checklist
• PUB394 Notification of Parents Rights Poster


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) or (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 informed of the MyChildCarePlan.org site, 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.


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 https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources /safe-sleep as an additional resource. 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.

On this date, 7/31/24, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Page 4.
SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KURUCULASURIYA FAMILY CHILD CARE
FACILITY NUMBER: 195700363
VISIT DATE: 09/11/2024
NARRATIVE
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Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

A notice of site visit was given to Applicant and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview conducted and report was reviewed with the Applicant. The applicant may be approved for a large family child-care once the following changes have been made by 9/27/2024 :
  • Safety locks added to the cabinets in the dinning room.
  • Door locks added to the off-limits rooms.
  • Removal of planter in the living room.
  • 5ft gate installed around the fish pond.
  • Able to test smoke/carbon monoxide detectors.

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.

Page 5.

SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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