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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313833
Report Date: 06/11/2025
Date Signed: 06/11/2025 09:05:48 AM

Document Has Been Signed on 06/11/2025 09:05 AM - 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:DASSANAYAKE, MENIKFACILITY NUMBER:
304313833
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 6CENSUS: 4DATE:
06/11/2025
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Menik DassanayakeTIME VISIT/
INSPECTION COMPLETED:
09:25 AM
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Licensing Program Analyst (LPA) Thompson conducted a case management inspection, in response to licensee request for a capacity increase. LPA met with licensee Menik Dassanayake then guided LPA on a tour of the facility. Licensee stated there is currently two adults living in the home and one minor child. Licensees stated she is not currently registered with any Foster Care agency or holds a foster parent license. Licensees reminded if changes are made to notify the licensing office. Facility Day care hours are 7:30 AM - 5:30 PM, Monday through Friday.

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.

This is a two story home with four bedrooms, three bathrooms, living room, family room, kitchen, dining room, front yard (not fenced), back yard (fenced), and a garage. The licensee acknowledged the children may never enter the off-limit areas during operation hours. Control of property was verified by LPA during today’s inspection. The licensees has a cell phone that is used for childcare. The licensees were informed if a cell phone is used for childcare, it must remain on the premises at all times during hours of operation. The licensees were informed and understands the home is to be free from smoking during hours of operation.

Areas Designated for Day Care Activities: The licensee has designated the living room, one bedroom located down stairs, one bathroom downstairs, and back yard.

Garage will not be used for day-care. The applicant stated the garage will be off-limit.

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NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Dean Thompson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2025
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: DASSANAYAKE, MENIK
FACILITY NUMBER: 304313833
VISIT DATE: 06/11/2025
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The facility has a fireplace located in the living room that is inaccessible to children in care. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Poisons and Hazardous items were not observed. There are no bodies of water. The toys are age appropriate and in good condition for the potential ages served. Baby walkers, bouncers, jumpers, and similar items will not be used for children in care. Licensee stated there are no weapons or firearms on the premises. LPA informed the licensees that when firearms are present, they must be locked and stored separately from the ammunition per CCR 102417(g)(4)(C).

During today's inspection, the smoke detector and carbon monoxide were operable, and the fire extinguisher was charged. Last emergency drill was conducted 04/02/2025.

Outdoor play activities will be conducted in the backyard, which is appropriately fenced. LPA observed play equipment to be safe and free of hazards.

Per licensee, she provides food for the children. LPA reminded licensee, that if food is not provided and food is brought from the children’s homes; container shall be labeled with child’s name and properly stored or refrigerated.



Per licensee, children will nap in the designated bedroom and living room. Per licensee, she uses a changing table to change the infants. LPA reminded licensee, while changing an infant’s diaper, visually observe the infant to ensure the infant is safe. Licensee stated she provides linen if parents forget to bring the linen for children.

Licensee Mandated Reporter certification expires 01/27/2027. The licensee American Red Cross Pediatric CPR/First Aid certification expires 12/02/2025.

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NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Dean Thompson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: DASSANAYAKE, MENIK
FACILITY NUMBER: 304313833
VISIT DATE: 06/11/2025
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The licensees have a current roster for children in care. During this inspection, LPA reviewed four children’s records and they were in compliance.

LPA advised the licensees how to access forms, regulations and quarterly updates online at: www.ccld.ca.gov

LPA discussed the safe sleep regulations with licensees 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 licensees 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing 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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensees were 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.

Licensees were reminded that all adults 18 and over, 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 Child Care Family 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.


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NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Dean Thompson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
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: DASSANAYAKE, MENIK
FACILITY NUMBER: 304313833
VISIT DATE: 06/11/2025
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Fire clearance granted on 05/28/2025.

During todays’ inspection, there were no deficiencies cited and licensee was in compliance with California Code of Regulations Title 22 for operating a Family Child Care home.

A new license for operating a Large Family Child Care Home shall be issued upon final review and if additional information is needed, licensee shall be contacted.

Exit interview conducted and report was reviewed with the licensee Menik Dassanayake. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

During the exit interview, the LICENSEE Menik Dassanayake, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.
NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Dean Thompson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC809 (FAS) - (06/04)
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