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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197492889
Report Date: 06/28/2022
Date Signed: 06/28/2022 12:36:59 PM

Document Has Been Signed on 06/28/2022 12:36 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:KANNANGARA FAMILY CHILD CAREFACILITY NUMBER:
197492889
ADMINISTRATOR:KANNANGARA,ATHUDARACHCHIGEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 217-9877
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:KANNANGARA, ATHUDARACHCHIGE DONA NATHASHATIME COMPLETED:
12:50 PM
NARRATIVE
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On 06/28/2022 Licensing Program Analyst (LPA), Suzette Ornelas conducted an unannounced Annual Required Inspection and was met by Licensee, KANNANGARA, ATHUDARACHCHIGE DONA NATHASHA. Also present was licensees mother who is her assistant. Days and hours of operation are Monday through Friday 7a to 6p.

LPA toured the home inside and outside and a census was taken. LPA observed 3 children in care in addition to her own two children. Current facility sketch reviewed and Licensee confirmed that the child care room towards the back of the home and the bathroom located in the hallway as soon as you enter the home are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of closed doors, safety door knobs, child proof gates and supervision. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible by the use of a baby gate which prevents access to the kitchen and are located on a high shelf making them inaccessible to children in care. LPA observed the child safety gate that prevents access to the kitchen/laundry room to be faulty. LPA advised licensee to ensure a properly functioning safety gate is installed. Licensee will provide proof of correction via email. The fireplace located in the living room is made inaccessible by a large couch placed in front of it and will not be in use during daycare hours. There is a working fire extinguisher located in the child care room which needs to be mounted and made inaccessible to children in care. There is a working smoke detector; however, the carbon monoxide detector is not in working conditions needs replacement batteries. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (818) 217-9877.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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 11
Document Has Been Signed on 06/28/2022 12:36 PM - It Cannot Be Edited


Created By: Suzette Ornelas On 06/28/2022 at 11:44 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: KANNANGARA FAMILY CHILD CARE
FACILITY NUMBER: 197492889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in the carbon monoxide detector did not have functioning batteries which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2022
Plan of Correction
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Licensee will replace batteries and provide LPA with a video via email showing the working carbon monxide detector.
Type B
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in safety gate preventing access to the kitchen is not secure which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2022
Plan of Correction
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Licensee will send picture via email to LPA showing baby gate is sturdy and secured to both sides of the doorway to the kitchen area.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/28/2022 12:36 PM - It Cannot Be Edited


Created By: Suzette Ornelas On 06/28/2022 at 11:44 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: KANNANGARA FAMILY CHILD CARE
FACILITY NUMBER: 197492889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview, record review)], the licensee did not comply with the section cited above in 2 adults did not have immunization records readily available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2022
Plan of Correction
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Licensee will provide proof of immunization records for herself and her mother and submit to LPA via email.
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 children were missing LIC627, and LIC9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2022
Plan of Correction
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Licensee will provide proof of signed parent copies via email to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 06/28/2022 12:36 PM - It Cannot Be Edited


Created By: Suzette Ornelas On 06/28/2022 at 11:44 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: KANNANGARA FAMILY CHILD CARE
FACILITY NUMBER: 197492889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 child did not have an LIC 995 A signed on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2022
Plan of Correction
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Licensee will provide proof of signed parent copy to LPA via email.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/28/2022 12:36 PM - It Cannot Be Edited


Created By: Suzette Ornelas On 06/28/2022 at 11:44 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: KANNANGARA FAMILY CHILD CARE
FACILITY NUMBER: 197492889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview record review, the licensee did not comply with the section cited above in 2 infants did not have form in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2022
Plan of Correction
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Licensee will submit proof of signed copy via email to LPA.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 infants did not have sleep log in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2022
Plan of Correction
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Licensee began documentation of infant sleep log immeadiately and will submit proof of 1 week of infants safe sleep log documentation to LPA via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022


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: KANNANGARA FAMILY CHILD CARE
FACILITY NUMBER: 197492889
VISIT DATE: 06/28/2022
NARRATIVE
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There are currently 2 infants in care. LPA discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are 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. LPA explained to the provider that mattresses are required in the infants play yard when sleeping. Currently, the play yards only have the bottom board for play time. Licensee will provide proof via email of play crib with mattresses. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes; however, does not documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. LPA provided licensee with a sample sleep log and explained the regulation/provided a copy of the regulation to the licensee. Infants up to 12 months of age are placed on their backs for sleeping. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is not completed and in file for each infant up to 12 months of age, LPA provided licensee with a copy of the form and explained the regulation/provided a copy of the regulation to the licensee. Infants up to 12 months of age are placed on their backs for sleeping.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced, however, licensee will ensure that the safety gate in the backyard area is reinstalled to ensure children do not have access to the off limits backyard area. Licensee will also ensure that the space between the two sheds in the backyard area is made inaccessible to children in care.Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were incomplete with emergency information as required. LPA observed 2 children were missing the LIC627, and LIC9227 and 1 child was missing the LIC 995A. Licensee’s Mandated Reporter Training has not been completed, LPA provided licensee with a copy of the regulation as well as the website to obtain certificate, licensee will submit proof of completion to LPA via email. Licensee’s pediatric CPR/First Aid expires on 2024. A review of records indicates that all employees and/or volunteers do not have immunization records on file for influenza, pertussis and measles, per licensee, she will submit proof of immunization records via email to LPA. Licensee will also submit proof of immunization records for MMR and Tdap for herself. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC809 (FAS) - (06/04)
Page: 10 of 11
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: KANNANGARA FAMILY CHILD CARE
FACILITY NUMBER: 197492889
VISIT DATE: 06/28/2022
NARRATIVE
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Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.
Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited:
Type B: 1597.543 - Carbon monoxide detectors required; inspection
Type B: 102417(g) - Operation of a Family Child Care Home
Type B: 1597.622(a)(1) - Employees or volunteers at family day care home; immunization requirements; records; exemptions
Type B: 102421(a) - Child's Records
Type B: 102419(d)(1) - Admission Procedures and Parental and Authorized Representative's Rights
Type B: 102425(c) - Infant Safe Sleep
Type B: 102425(j)(2)(D) – Infant Safe Sleep
(see next page, 809 D) Licensee was provided a copy of appeal rights.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC809 (FAS) - (06/04)
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