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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 214005440
Report Date: 10/05/2021
Date Signed: 10/07/2021 08:08:54 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/29/2021 and conducted by Evaluator Haydee R Caliboso
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20210929133006
FACILITY NAME:DE SILVA, NIROSHAFACILITY NUMBER:
214005440
ADMINISTRATOR:DE SILVA, NIROSHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 827-7477
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY:14CENSUS: 0DATE:
10/05/2021
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:De Silva NiroshaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
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9
Provider is not practicing PPE
Provider is not notifying parents when an incident or injury has occurred
Provider closes door during nap time
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
8
9
10
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13
On 10/5/21 at 12:45pm., Licensing Program Analyst (LPA) Haydee Caliboso arrived at the home to conduct a 10- day complaint inspection in response to above allegations.
Present during the inspection was the husband's Licensee, Nirosh De Silva. No children were present during the inspection. At 1:10pm, Licensee Nirosha De Silva arrived at home.

Based on LPA's gathered information through interviews with the Licensee, the agency has investigated the complaint allegations above. Licensee and staff wear masks while providing care, however periodically do not wear the masks properly as per Department of Public Health guidelines. Licensee and staff will continue to work on properly wearing face coverings while providing care. Licensee and staff notify the child's authorized representative when a child gets injured while in care or when there is an incident when Licensee and Staff are made aware of an injury or incident. Licensee states she will make sure to provide written notes and telephone the authorized representative immediately when a child has an incident. Licensee and staff do not close the door to the room where children are napping. Licensee states they open or access the pantry door located at the hallway to get supplies, but the hallway is wide enough to walk into the room when needed and/or to be able to hear and see the children during naptime. Technical assistance was provided.

Although the allegations of Licensee not practicing PPE; not notifying parents when an incident or injury has occurred; and Licensee closed door during nap time may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are found to be 'Unsubstantiated.'
Appeal Rights were provided to the facility. This report and rights to comment and appeal have been discussed. This report and Notice of Site Visit will be emailed to Licensee at
weekidzcare@yahoo.com
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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