<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018763
Report Date: 04/11/2023
Date Signed: 04/11/2023 12:57:16 PM

Document Has Been Signed on 04/11/2023 12:57 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:DE SILVA FAMILY CHILD CAREFACILITY NUMBER:
198018763
ADMINISTRATOR:HEWA KOSGODAGE DE SILVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 331-4221
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
04/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Hewakosgodage DeSilva, LicenseeTIME COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
 On April 11, 2023, Licensing Program Analyst (LPA) Dayna Chambers conducted an unannounced case management inspection. LPA Chambers arrived at the home at 9:30am. The licensee was not present at the time of arrival. LPA called the licensee that LPA was at the door. At 10:00am, Licensee returned home and met with Licensee Hewakosgodage DeSilva. There were no children present during inspection.
Licensee did not report or submit the LIC624B unusual incident report to Monterey Park Southwest Office when they became aware of the incident. LPA interviewed the licensee, reviewed child’s records, roster, and documentation. On December 22, 2022, Child #1 was playing in the backyard with Staff #1 supervising. Staff #1 observed the child who was playing fall but did not report the incident to the licensee. Staff #1 did not observe injuries requiring medical attention and did not notify licensee at the time of occurrence. Licensee was not notified until after Staff#1 left the home in the evening.
During inspection: LPA issued reporting requirements: Title 22 Regulations, LIC624B form, Title 22 Personal Rights, advised to inform parents for procedures for registering complaints, LIC311D for recordkeeping, PM286 for recordkeeping, and safe sleep resources- LIC9227, 15-minute sleep chart, Infant Safe Sleep Title 22 resources to licensee.
Based on information obtained while interviewing licensee, LPA determined there was a violation that resulted from the incident. Reporting Requirement Deficiency were cited on this date; Licensee did not meet reporting requirements for this incident.
The deficiency listed on the following page were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.
Exit interview was conducted with Licensee Hewakosgodage DeSilva. A copy of this report was provided. Notice of Site Visit was issued and must remain posted in the facility for 30 days. Failure to do so will result in a civil penalty.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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 2
Document Has Been Signed on 04/11/2023 12:57 PM - It Cannot Be Edited


Created By: Dayna Chambers On 04/11/2023 at 12:43 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: DE SILVA FAMILY CHILD CARE
FACILITY NUMBER: 198018763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2023
Section Cited
CCR
101212(d)

1
2
3
4
5
6
7
101212(d)(1)(B) Reporting Requirements

(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
1
2
3
4
5
6
7
Licensee will complete: POC: Title 22 Regulations provided – Read with Staff
Operation of a childcare family home, reporting requirements, and infant safe sleep, Infant Safe Sleep FAQs provided during visit.
Watch CCLD provider Videos- Watch with Staff
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on information provided during interview with licensee and FAS record review, the licensee did not comply with the reporting requirement regulations,
which poses a potential health and safety risk
to children in care.
8
9
10
11
12
13
14
www.ccld.childcarevideos.org
1. Child Care Reporting Requirements
2. Supervising Children for Family Homes
3. Children’s Personal Rights
Reporting Requirements Video: Provided the LIC624B for family homes to send written report. Call main office number 323-981-3350 within the first 24 hours to report unusual incident. Within 7 days, email the written Licensing report to: MPSWreportingrequirements@dss.ca.gov
Notify LPA by April 17, 2023 after completing with staff by email.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Valarie Cook
LICENSING EVALUATOR NAME:Dayna Chambers
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2