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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312736
Report Date: 05/14/2025
Date Signed: 05/14/2025 12:50:22 PM

Document Has Been Signed on 05/14/2025 12:50 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MEDAGANGODA, ROHITHAFACILITY NUMBER:
304312736
ADMINISTRATOR:MEDAGANGODA, ROHITHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 318-5511
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 12DATE:
05/14/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Staff-Valeria, RodriguezTIME COMPLETED:
01:00 PM
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On 5/14/2025, an Annual Random inspection was conducted at the facility by Licensing Program Analysts (LPA) K. Navar. LPA observed 2 assistants caring for 12 children. S1 stated that licensee has stepped out and will be right back. Licensee arrived about 15 minutes later and met with LPA. Licensee was operating within the licensed capacity as specified on the license.

A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Family childcare home day care hours are 7:30 am-6:00pm, Monday through Friday. During today’s inspection the LPA observed 12 children engaged in activities in the day care area with an assistant. LPA verified there is a working telephone service (cellular service), licensee was reminded that childcare phone needs to remain the in the childcare at all times.

During today’s inspection, LPA and assistant toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas are made inaccessible by the means of door locks. The home has age-appropriate toys for the ages served. Children nap in day care area on mats and parent/guardians bring food from home.

Licensee stated they use the back patio/yard for outdoor play and that there is no pool at the facility. Backyard has age-appropriate toys and free of hazards. There are working carbon monoxide, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. There were no poisons observed which could pose a danger to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspection. There is a fireplace that is disconnected. The licensee has completed a disaster drill on 4/11/2025.

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NAME OF LICENSING PROGRAM MANAGER: Judy Hanson
NAME OF LICENSING PROGRAM ANALYST: Karen Navar
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2025
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MEDAGANGODA, ROHITHA
FACILITY NUMBER: 304312736
VISIT DATE: 05/14/2025
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The licensee had a roster of children up to date. 5 (three) children’s records for children present during LPA’s inspection were reviewed. There was a separate and complete file for each child with (LIC 700), Immunization records, Affidavit Regarding Liability Insurance (LIC282), Consent for Emergency Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995A).

The licensee had proof of EMSA approved Pediatric CPR/First Aid certification with expiration date 11/2025. Beginning September 1, 2016, Health and Safety (H&S) pertussis, measles, and influenza immunizations are required. Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. 3 staff files including licensees was reviewed for compliance. 2 of 3 staff files were in compliance. 1 staff file was missing pertussis immunization and child mandate reporter training certificate. S2 stated they will add to file right away.

Incidental Medical Services (IMS) policy was discussed. Licensee stated there is there are no children enrolled at this time who take medication. For IMS information see PIN 22-02- CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/

The licensee understands they must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

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NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Karen Navar
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MEDAGANGODA, ROHITHA
FACILITY NUMBER: 304312736
VISIT DATE: 05/14/2025
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CCLD website www.cdss.ca.gov/inforesources/community-care-licensing was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

LPA’s 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 [facility representative] 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 childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

Based on LPAs observations, record reviews and interviews there are no violations being cited in accordance during today’s visit.

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.

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NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Karen Navar
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MEDAGANGODA, ROHITHA
FACILITY NUMBER: 304312736
VISIT DATE: 05/14/2025
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Exit interview conducted and report was reviewed with the licensee Rohita, Medagangoda. A notice of site visit was given and must remain posted for 30 days.

End of Report.

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.
NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Karen Navar
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC809 (FAS) - (06/04)
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