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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005601
Report Date: 10/08/2024
Date Signed: 10/08/2024 02:27:57 PM

Document Has Been Signed on 10/08/2024 02:27 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, NIROSHAFACILITY NUMBER:
214005601
ADMINISTRATOR/
DIRECTOR:		DE SILVA, NIROSHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 827-7477
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
10/08/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:24 AM
MET WITH:NIROSHA DESILVATIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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On October 8, 2024, Licensing Program Analyst (LPA) Garcia arrived at the facility to conduct an unannounced Annual Inspection and met with the Licensee, Nirosha Desilva and her husband. Purpose of the inspection was explained. There were 7 children present which 4 were infants and 3 children over the age of two. LPA verified the background check clearance of the adults working or living in the home. As of today's visit, the Licensee is compliant with ratio. The hours of operation are Monday through Friday, 08:00 AM - 4:30 PM. Per Licensee, she provides morning and afternoon snacks and lunch. The water is provided by the licensee through filtered water services.

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 perform the tests to check the functionality of the detectors due to children napping. One fully charged fire extinguisher of size 3A40BC was also available in the home, located by day care room. First Aid kit is fully stocked and accessible, located in the day care area counter. Licensee states, there are no guns or weapons or pools. LPA observed that an infant child had a pacifier beside him with a string attached to it.

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 has LIC 282 on file. LPA advised the licensee to organize the documentation of children and her own. Licensee was also given a chance to update the facility roster during the visit.

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SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 10/08/2024
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LPA observed that the outdoor areas are in good condition that includes playhouses, slides, tables and toys on artificial grass.

All posting requirements are met and posted near the childcare entrance. Licensee has current and valid CPR and First Aid card which expires on 10/2025. Licensee was unable to show valid Mandated reporter training certificate. LPA observed that the emergency log was not updated with their most recent drill. LPA reviewed licensee's files and 4 children's files. The licensee was unable to show proof of 2 child's file. LPA observed that necessary documents are not filed for both Licensee and children in care. The missing documents include, sleep logs for the infants and licensing documents that must be signed by parents.

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.

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.

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.

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SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
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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: 10/08/2024
NARRATIVE
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LPA reviewed AB 1207 with the Licensees. 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.



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 atwww.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 at6: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.

See LIC 809D page for the deficiencies cited during the visit.

A copy of this report is given to the Licensee with the notice of site visit. Notice of site visit must be posted for 30 days. 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 Desilva. Report will be emailed to licensee due to printer malfunction. Confirmation of receipt is required .
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Nathan Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2024 02:27 PM - It Cannot Be Edited


Created By: Nathan Garcia On 10/08/2024 at 02:12 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: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(b)(1)(A)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (1) Pacifiers shall be allowed in the crib or play yard if the following provisions are in place: (A) There shall not be anything attached to the pacifier.

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 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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The licensee removed the pacifier from the child's crib during the visit. Deficiency will be cleared during the visit.
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.
SUPERVISOR'S NAME:Daniel J Oquendo
LICENSING EVALUATOR NAME:Nathan Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2024 02:27 PM - It Cannot Be Edited


Created By: Nathan Garcia On 10/08/2024 at 02:12 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: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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The licensee will continue to take sleep logs of infants for every 15 minutes. Proof of this documentation will be sent to LPA be set due date. LPA advised to keep logs for children up to two years of age.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (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: 11/08/2024
Plan of Correction
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The licensee and her husband will take the mandated reporter training and send the certificate to LPA be set due date.
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: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 10/08/2024 02:27 PM - It Cannot Be Edited


Created By: Nathan Garcia On 10/08/2024 at 02:12 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: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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The Licensee will send verification of all the Licensing documents of each child to LPA by set due date.
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.
SUPERVISOR'S NAME:Daniel J Oquendo
LICENSING EVALUATOR NAME:Nathan Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
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