214005601-11-28-2023-05-CC-NGAA-CY239Q-20231128170331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214005601
Report Date: 11/28/2023
Date Signed: 11/28/2023 05:03:42 PM

Document Has Been Signed on 11/28/2023 05:03 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	DE SILVA, NIROSHA		FACILITY NUMBER:	214005601
ADMINISTRATOR:	DE SILVA, NIROSHA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 827-7477
CITY:	NOVATO	STATE: CA	ZIP CODE:	94949
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 4	DATE:	11/28/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	01:49 PM
MET WITH:	Nirosha De Silva		TIME COMPLETED:	05:25 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 November 28, 2023, Licensing Program Analyst (LPA) Nathan Garcia arrived at the facility to conduct an unannounced required inspection and met with the Licensee, Nirosha De Silva. Purpose of the inspection was explained. There were 4 children and a helper with the licensee present in the home. LPA verified the background check clearance of the adults working or living in the home. The hours of operation are Monday through Friday, 08:00 AM - 4:30 PM. Licensee provides AM snacks, Lunch and PM Snacks. Filtered water is provided for refill through dispenser, if needed. Daycare areas: Living room, kitchen, backyard and bathroom. Off Limit areas: Bedrooms, Garage, entire upstairs. LPA observed that off limit areas were properly barricaded and made inaccessible to the children in care. LPA and Licensee inspected the entire childcare area for Health and Safety hazards. There are multiple carbon monoxide and smoke detectors located in each room. LPA did not performed the tests to check the functionality of the detectors due to napping. One fully charged fire extinguisher of size 3A40BC was also available in the home, located in the kitchen. First Aid kit is fully stocked and accessible. Licensee states there are no guns or weapons in the home. There are no pets or open bodies of water in the home. LPA observed that the house is in good repair and free of hazards with proper temperature and ventilation and lighting. The play area is clean, padded/carpeted and in good condition. LPA observed that there are variety of age-appropriate toys, books, and other learning materials available in the home. Electric outlets have proper covers and a working phone is on site. The Licensee does not have liability insurance available. LPA observed that the day care area has play set materials neatly organized. *continue to page 2*

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DE SILVA, NIROSHA	FACILITY NUMBER: 214005601
	VISIT DATE: 11/28/2023

NARRATIVE

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All posting requirements are met and posted near the childcare entrance. Licensee and staff has current and valid CPR and First Aid card expiring on 10/2025. Mandated reporter training certificate is expired for Licensee and staff. LPA reviewed facility records. Four children's records were reviewed and 1 child is missing their file. The facility conducts fire and earthquake drills with the children at least every 6 months. The most recent one was in August 14, 2023.

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.

Per Licensee, there is one child with allergy and Epipen is in the child's bag. Incidental Medical Services (IMS) policy was discussed. For IMS information 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: on 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 www.ada.gov/childqanda.htm.

The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

LPA reviewed AB 1207 with the Licensee. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. Effective July 1, 2020, Licensees must have proof of completion of EMSA certified lead poison training if applying for a change of location or capacity change to an existing license.
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SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DE SILVA, NIROSHA	FACILITY NUMBER: 214005601
	VISIT DATE: 11/28/2023

NARRATIVE

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LPA encouraged the Licensee to visit the Licensing website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

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.

LPA discussed the safe sleep regulations with licensee 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 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 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.

A copy of this report was given to the Licensee and a site visit notification must be posted for 30 days.

Type B violation for missing LIC 9227 infant child.

Technical Violation for child's record keeping and expired mandated reporter training certificate.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee, Nirosha De Silva.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/28/2023 05:03 PM - It Cannot Be Edited

Created By: Nathan Garcia On 11/28/2023 at 04:59 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: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/28/2023
	Plan of Correction
1 2 3 4	The licensee will send confirmation of the LIC forms being filled out by the authorized representatives.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Daniel J Oquendo

LICENSING EVALUATOR NAME:

Nathan Garcia

LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

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