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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005601
Report Date: 10/05/2021
Date Signed: 10/27/2021 05:18:58 PM

Document Has Been Signed on 10/27/2021 05:18 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:DE SILVA, NIROSHAFACILITY NUMBER:
214005601
ADMINISTRATOR:DE SILVA, NIROSHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 827-7477
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
10/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:11 PM
MET WITH:De Silva NiroshaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Haydee Caliboso arrived at the Licensee's previous licensed location (#214005440). Present during the inspection investigation was Licensee's husband. LPA explained the reason for the inspection. Licensee’s husband stated Licensee Nirosha De Silva, was at their new home, which is pending licensure for a ‘change of location’ (#214005601). Licensee’s husband stated Licensee is providing care at the new home since they had to vacate their currently licensed home. LPA previously inspected ‘change of location’ facility on 09/28/21, and facility is pending fire clearance for a large capacity license.

At 1:15pm, Licensee, Nirosha De Silva, arrived at licensed location at the previous home.

>See attached page for deficiencies issued today under Title 22 Division 12 of the CA. Code of Regulations.




This report will be kept in the Facility File and will be made available for Public Review upon request. Website for Forms and Regulations: www.ccld.ca.gov. Appeal Rights were provided to the facility. This report and rights to comment and appeal have been discussed.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2021 05:18 PM - It Cannot Be Edited


Created By: Haydee R Caliboso On 10/05/2021 at 08:29 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DE SILVA, NIROSHA
FACILITY NUMBER: 214005601

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2021
Section Cited
HSC
102357

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102357
Operation Without a License
The Department has reason to believe that family child care is being provided without a license. This evidence is met by:

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Facility is currently pending Fire clearance at ‘relocation site/home’ due to using the ‘Toy Room’ (converted Garage) as day care area. Licensee will make the ‘Toy Room’ off limits and will submit an updated LIC 999A Facility Sketch indicating areas where child care will be provided and will indicate the ‘Toy Room’ (converted Garage) as an off limit area.
Licensee will either follow up with Fire department to obtain fire clearance or will withdraw application for Large Family Day Care Home and will apply for Small Family Day Care Home.

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This requirement was not met as evidenced by: LPA’s inspection on 10/05/21 and per Licensee’s disclosure, Licensee is operating unlicensed care at their ‘relocation’ site/home. Licensee states she is caring for 8 children. This poses a potential health and safety risk to children in care.
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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.
SUPERVISOR'S 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2021


LIC809 (FAS) - (06/04)
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