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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018763
Report Date: 10/29/2025
Date Signed: 10/29/2025 04:36:57 PM

Document Has Been Signed on 10/29/2025 04:36 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:DE SILVA FAMILY CHILD CAREFACILITY NUMBER:
198018763
ADMINISTRATOR/
DIRECTOR:		HEWA KOSGODAGE DE SILVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 331-4221
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 6DATE:
10/29/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:HEWA KOSGODAGE DE SILVA, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Alicia Mooberry conducted an unannounced Annual Random Inspection on this date. Upon arrival at 1:15 LPA met with Hermelinda Nunez, Assistant (Staff 1) and informed of the purpose of inspection. Also present was Dinali Alawi, (staff 2). LPA was allowed entry into the home and LPA inspected rooms/areas on the facility sketch in which child-care services are provided and to which children have access. Per licensee the current hours of care provided are Monday – Friday 6:00am - 6:00pm. At ovided form LIC 126, Inspection Entrance Checklist. At 1:26pm LPA observed 4 children napping in the living room, 1 infant was observed napping in crib with blanket covering the body and another blanket hanging on side of the crib, children were supervised by staff 1, this poses a potential risk to the health and safety of children in care. LPA observed 3 additional children in the kitchen and adjacent play room supervised by staff 2.The licensee arrived at 1:46. All adults present have obtained the required background clearance and are associated to the facility. Individuals residing in the home were discussed and noted.

This facility is the front home of a is a two story home which consists of three bedrooms, three bathrooms.

Areas used by the day care children include the living room, dining room, playroom, downstairs bathroom, and backyard. Per Licensee, areas off limits to children and parents include: The entire 2nd level-three bedrooms, and two bathrooms, Lower level: garage, kitchen and front yard. Food is provided by Licensee and if children bring food from home it labeled with the child’s name and properly stored or refrigerated.

LPA observed the facility license, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form posted on parent board next to dining room. Licensee was reminded ensure the required posted documentation are located visible to parent/guardians of children in care. LPA reviewed Children’s Roster form LIC 9040 and Emergency Disaster Plan (LIC 610A) --Pg 1 of 3

NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Alicia Mooberry
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: DE SILVA FAMILY CHILD CARE
FACILITY NUMBER: 198018763
VISIT DATE: 10/29/2025
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The home is observed to be clean and orderly. Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged and was serviced on 1/27/25.The home maintains telephone service via cell phone/LAN line. There are toys and other age-appropriate material available.
LPA observed that cleaning compounds are in kitchen and on overhead shelf in children's bathroom inaccessible to children in care. The bathroom that children use is in the dining room area and observed to be clean and free of accessible hazards.

Licensee states that there are no poisons stored in the home. Per Licensee there are no firearms or weapons stored in the home. LPA did not observe any pools, spa or similar body of water on the premises. No pets are in the home at this time.
Per Licensee, area for children that become ill during care is in the living room where children are supervised and away from the other children.

Outdoor play area is in the back yard and observed to be fenced. there are age appropriate preschool toys and climbing toys, there is artificial grass covering the entire backyard space and adequate shading. No hazards were observed. The licensee was advised to regularly check to toys for loose parts, sharp edges, spiders and other hazards.

Five Children’s records were reviewed including 2 infant files and were found to be complete.


Licensee and 2 staff files 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. Staff 2 was missing facility file. Immunizations were provided including MMR, TDAP and Influenza, the TB clearance was missing posing a potential risk to the health and safety of children in care.

LPA discussed the safe sleep regulations with licensee including PIN 20-24-CCP. 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 reminded licensee of requirement to be present in the home and to ensure that children in care are supervised at all times. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. ----Page 2 of 3

NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Alicia Mooberry
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: DE SILVA FAMILY CHILD CARE
FACILITY NUMBER: 198018763
VISIT DATE: 10/29/2025
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, 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.

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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee [or facility representative] was informed of the MyChildCarePlan.org website; 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.

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.

Based on the LPA's observations and records review 3 B deficiencies will be cited today in accordance with California Title 22 Regulations.

A notice of site visit was given and must remain posted for 30 days. Appeal Rights were discussed and provided.

Exit interview conducted and report was reviewed with the licensee Hermelinda Nunez.

NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Alicia Mooberry
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2025 04:36 PM - It Cannot Be Edited


Created By: Alicia Mooberry On 10/29/2025 at 03:53 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: 10/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

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 that 1 out of 1 infant napping in crib had blanket over their torso and there was an additional blanket hanging from side of crib (photo taken) which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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During visit the infant, Child 1, was removed from the crib and was picked up by authorized representative. Per licensee, they will review the Safe Sleep regulations including PIN 20-24-CCP with staff to make sure the safety of infants in care.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in 1 out of 3 adults present in home and workign with children in care does not have the proof of Tuberculosis clearance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2025
Plan of Correction
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Per licensee, Staff 2 will obtain proof of Tuberculosis clearance and a proof will be sent to LPA by POC due date 11/12/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Warren Birks
NAME OF LICENSING PROGRAM MANAGER:
Alicia Mooberry
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2025 04:36 PM - It Cannot Be Edited


Created By: Alicia Mooberry On 10/29/2025 at 03:53 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: 10/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 3 staff present in the home does not have a facility file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2025
Plan of Correction
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The licensee will complete a facility file for Staff #2 to include: Employee's full name, A signed and dated copy of the Notice of Employee Rights [LIC 9052, Date of employment, Date of birth, Current home address and phone number.
The licensee will inform LPA of completed employee file by POC due date 11/11/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Warren Birks
NAME OF LICENSING PROGRAM MANAGER:
Alicia Mooberry
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2025


LIC809 (FAS) - (06/04)
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