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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197492889
Report Date: 01/21/2025
Date Signed: 01/21/2025 04:14:15 PM

Document Has Been Signed on 01/21/2025 04:14 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:KANNANGARA FAMILY CHILD CAREFACILITY NUMBER:
197492889
ADMINISTRATOR/
DIRECTOR:		KANNANGARA,ATHUDARACHCHIGEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 217-9877
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
01/21/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:A. KannangaraTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tatiana Bickham conducted an unannounced annual required inspection at the above facility on 1/21/2015 at 2:15 PM. Upon arrival, LPA disclosed the purpose of the inspection and met with A. Kannangara License, who guided LPA on a tour of the facility. Entrance Checklist – Family Child Care Homes LIC 126 was provided to the Licensee’s to help facilitate the inspection. Also present was Licensee’s assistant. There were (seven) 7 day care children present during today’s inspection. Per Licensee, there are currently (seven) 7 children enrolled. Facility capacity is in compliance for a large Family Child Care Home. Hours of operation are Mon-Fri 7:00 AM - 6:00PM.

LPA toured the home inside and outside. This is a one-story home which consists of 3 bedrooms, 2 bathrooms, day-care room, kitchen, dining room, living room, detached storage room, front yard and backyard (fenced).



Per Licensee, areas off limits to children and parents include: All 3 bedrooms, 1 bathroom, kitchen, front yard, and 1 detached storage room in the backyard.

Per Licensee, areas that are accessible to children include: Living room, dining room, day-care room bathroom, and backyard. The bathroom that children use is located next to the front door and was observed to be clean and free of hazards.

Food is provided by Licensee. Licensee was reminded if children bring food from home, it must be labeled with the child’s name and properly stored or refrigerated.

Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption.

Page 1.
SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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 10
Document Has Been Signed on 01/21/2025 04:14 PM - It Cannot Be Edited


Created By: Tatiana Bickham On 01/21/2025 at 03:13 PM
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: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

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 in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee must ensure the day-care room and backyard are orderly during operation hours. Licensee will provide picture to LPA.
Type B
Section Cited
CCR
102425(a)(3)
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. (3) Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged.

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 in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee must ensure each infant has a fitted sheet and will write a statement stating Licensee understands infants can not be placed in a crib/play yard with a non fitted sheet.
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:Raul Navarro
LICENSING EVALUATOR NAME:Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 01/21/2025 04:14 PM - It Cannot Be Edited


Created By: Tatiana Bickham On 01/21/2025 at 03:13 PM
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: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 3 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee will email LPA 15-minute safe sleep for infants by date listed above. Must be filled out each day the infant naps and must be completed for each infant 0-24 months.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 2 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Licensee and Licensee assistant will complete training by the date listed above and email certificate to LPA. Training can be completed at www.mandatedreporterca.com
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:Raul Navarro
LICENSING EVALUATOR NAME:Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 01/21/2025 04:14 PM - It Cannot Be Edited


Created By: Tatiana Bickham On 01/21/2025 at 03:13 PM
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: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 1 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Licensee will submit proof of completed Pediatric CPR/First Aid by the date listed above and email certificate to LPA.
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 and record review, the licensee did not comply with the section cited above in 2 out of 2 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Licensee and Licensee assistant shall submit proof of vaccinations against influenza, pertussis, and measles but the date listed above. Influenza (Flu) must be completed within the last year or a letter declining to take the Influenza vaccine is required.
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:Raul Navarro
LICENSING EVALUATOR NAME:Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


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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: KANNANGARA FAMILY CHILD CARE
FACILITY NUMBER: 197492889
VISIT DATE: 01/21/2025
NARRATIVE
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All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection:

LPA reviewed required posted documentation for Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill was not conducted within the last 6 months.

Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged but was purchased/serviced within the year. The home maintains telephone service via cell phone. The day-care room was cluttered with toys and was not orderly. Per Licensee, there are extra toys in the day-care room due to the high winds that were in the area last week. There are toys and other age-appropriate materials available for children. Fireplace is positioned behind the couch to prevent access by children. LPA observed that detergents, cleaning compounds and medication are stored in the kitchen in the top shelf, inaccessible to children. Licensee states that there are no poisons stored in the home and understands that all poisons must be lock, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in living room, away from the other children. Per Licensee there are no firearms or weapons stored in the home.

Infant Care: Currently licensee cares for 3 infants. LPA observed 3 play yards visible in the day-care room. Napping equipment does not block entrances or exits. Infant mattresses were observed to be firm, LPA observed one play yard to not have tightly fitted sheets. LPA informed Licensee each infant must have a fitted sheet, LPA advised Licensee to have additional sheets for the infants so each play yard can have a fitted sheet. LPA did not observe loose object, bumpers, objects hanging, or objects attached to the play yards. Per licensee wet or soiled sheets are removed, placed in a bag, and given to the parents to wash. Each infant has their own play yard and bedding. Bedding is given to the parents to be washed weekly. LPA informed licensee of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, and provided PIN 20-24-CCP. Licensee states the following sleep supervision plan for infants: One person stays inside of the room with the infants.

Page 2.

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

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
Page: 7 of 10
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: KANNANGARA FAMILY CHILD CARE
FACILITY NUMBER: 197492889
VISIT DATE: 01/21/2025
NARRATIVE
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Overnight Care: Per Licensee, no overnight care is provided.

Currently, children are using the back yard for outdoor play. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA observed broken toys and objects that could be hazardous to children in care. There are no pools or spas, or other bodies of water.



Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunizations Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months) Licensee were incomplete for one child and was missing entire records for two children.

Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunizations against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate. Licensee and Licensee assistant did not have a current Mandated Reporter Training certificate, current Pediatric CPR/First Aid and proof of immunizations against measles, pertussis and influenza.

— Pediatric First Aid and CPR expires: 03/2024
— Mandated Reporter AB1207 expired: No certificate

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful, and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

Incidental Medical Services (IMS): Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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
Page 3.
SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
Page: 8 of 10
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: KANNANGARA FAMILY CHILD CARE
FACILITY NUMBER: 197492889
VISIT DATE: 01/21/2025
NARRATIVE
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Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Center and the ADA, available at: http://www.ada.gov/childqanda.htm

Licensee 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.

Licensee was reminded of their responsibility to report suspected child abuse. Mandatory Forms for the children’s files and provider’s files were discussed. Licensee was made aware that state law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category. Licensee was reminded that all infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome), and that the Provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome. 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. Licensee was also reminded that only children eating may be in highchairs and that car seats are utilized only for transportation.



Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

The licensee was advised the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, (Type A violation), a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. The Licensee was made aware they may file an appeal, in writing 15 business days from the date of receiving the penalty assessment.

During the exit interview, the LICENSEE, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Page 4.

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

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
Page: 9 of 10
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: KANNANGARA FAMILY CHILD CARE
FACILITY NUMBER: 197492889
VISIT DATE: 01/21/2025
NARRATIVE
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Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Page 5.

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

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
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