304313980-2-10-2022-06-CC-KDEI-CBJ2LW-20220210163013

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313980
Report Date: 02/10/2022
Date Signed: 02/10/2022 04:30:38 PM

Document Has Been Signed on 02/10/2022 04:30 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	LEELARATNE, SUMUDU		FACILITY NUMBER:	304313980
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 1	DATE:	02/10/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Applicant Ms. Leelaratne, Sumudu		TIME COMPLETED:	04:45 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	Licensing Program Analyst (LPA) Desai, Ketki conducted an announced in-person Pre-Licensing inspection for a new Small Family Child Care home. LPA met with the applicant Ms. Leelaratne, Sumudu who provided a tour of the new home. It is a Relocation. A review of the Facility Personnel Report Summary indicates adult residents, who require caregiver background check clearances, transfers, exemptions have been obtained and they are cleared. Applicant stated, she is not currently registered with any Resource Foster Care agency or holds a Resource foster parent license. Applicant was reminded if changes, to notify the licensing office. The applicant is requesting a Small family childcare home license. Per applicant, operation hours will be Monday to Friday 7:30 AM to 5:30 PM and care and supervision shall be provided to children ages newborn to 6 years of age. (Infants to School age only) All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a two story home with 3 bedrooms, 2 and half bathrooms, living area, kitchen, dining area, loft room, open back yard with 2: side yards and an attached garage. (Laundry area is in the garage) Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone is the primary contact phone. Ventilation and heating. The home has a central air and heating system and the unit is installed in the side yard in the off limit area. There is a stairway in the home leading to the second level of the home and it has a child safety barrier installed at the beginning of the stairway. Fire place is in living room, but it has been completed covered with brinks and colored. . Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The applicant states (that there are no poisons on the premises). Applicant was advised that any poisons must be locked with a key or combination lock. (1)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LEELARATNE, SUMUDU	FACILITY NUMBER: 304313980
	VISIT DATE: 02/10/2022

NARRATIVE

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Based on the Facility Sketch submitted, areas off limits to children and parents are: Applicant has designated entire second level of the home, kitchen with dining area, two side yards with the attached garage as off-limits areas. There is a child safety gate installed on the stairway, making the second level inaccessible. Applicant has also installed a safety gate at the entrance of the dining area making the kitchen and dining area inaccessible, however children will walk through the dining area to access the back yard. Kitchen is open adjoining the dining area, all the cabinets have child safety locks installed making it inaccessible to children. Garage door is next to the children's bathroom it has two bolted locks installed making the garage completely inaccessible to children. Side yards are completely off limits and Applicant shall install a safe fence surrounding the covered patio area making it inaccessible to children.

During the Pre-licensing inspection, LPA observed the designated off limits areas were closed and locked.

The applicant shall use the Cell phone for Day care activities and applicant was informed if a cell phone is used for child care, it must remain on the premises at all times during hours of operation. Applicant was informed and understands the home is to be free from smoking during hours of operation.

Applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

Areas Designated for Day care activities: Applicant has designated the living room, one half bathroom, and part back yard (Covered patio area) for Day care activities.

The children shall enter through the main door of the home into the living area the designated Day Care room. The designated Child Care room was observed to have age appropriate toys, arts and craft materials, books and educational items including age appropriate furniture. Children shall nap in this area. Children shall nap on mats, linens and blankets shall be provided by the parents and applicant does have additional linens if needed.

Infant Care: Applicant has items for Infant care : Bassinet, crib, Portable pac & play, changing table/ high chair, potty chair and step stool.

Upon entrance through the designated main door of the home applicant shall receive the children here, due to pandemic parents are encouraged to follow CDC guidelines, upon entrance temperatures shall be checked, hands shall be sanitized, before children are guided into the designated day care areas. (2)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LEELARATNE, SUMUDU	FACILITY NUMBER: 304313980
	VISIT DATE: 02/10/2022

NARRATIVE

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Applicant shall provide Breakfast /Lunch along with AM/ PM snacks, if food is brought from home and these containers shall be labelled with their names by the parents and stored accordingly.

The bathroom is located in the dining area, next to the garage door, on the left hand side of the small hallway, children shall walk from the living area to access the bathroom. It was observed to be safe and free of hazardous items. The side cabinet with door remains empty. Applicant has a toddler potty chair / step stool, she plans to provide toilet training to the young toddlers.

OUTDOOR PLAY AREA: Applicant have designated the covered patio area for outdoor activities for enrolled children. The backyard is completely fenced covered with concrete flooring. Outdoor play equipment's are arranged under the shaded area , Applicant plans to install fencing surrounding the shaded area, making the part of the back yard and side yards inaccessible to children.

Per applicant there are two guinea pigs as pets: They shall remain in the garage in the cage during operating hours.

There are no firearms, weapons in the home.

Bodies of Water: Licensee has one spa in the back yard. Spa is covered with a durable cover, but it needs to be locked. At this time the Bodies of Water does not meet the regulation. Applicant shall complete the needed corrections in the back patio area with the bodies of Water & fencing to be in compliance.

The value on the 2A10BC fire extinguisher indicates fully charged, as indicated on service tag observed. Smoke and carbon monoxide detectors were tested and are operable. Applicant has placed the Fire extinguisher in the closet in the day care room. Applicant have completed the required Mandated Reporter Child Abuse training, Health and Safety training with Nutrition and Lead Poisoning component and Pediatric First Aid and CPR which is valid through 9/1/2022 There are first aid supplies available.

The following was discussed with the applicant:·Applicant Ms. Leelaratne, Sumudu 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. (Page-3)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LEELARATNE, SUMUDU	FACILITY NUMBER: 304313980
	VISIT DATE: 02/10/2022

NARRATIVE

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In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR certification, TB clearance along with a valid criminal record clearance associated to the facility license.

Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
·The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

Applicant was also made aware of the Child Advocacy program so she could receive the updated Quarterly reports and other information in a timely manner. (Ms. Leelaratne, Sumudu indicated she has been receiving all the updates and PIN's)

Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

Fire and safety drills must be performed every six months and documented for review by the Department.

Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
No smoking, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients. (Page-4)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LEELARATNE, SUMUDU	FACILITY NUMBER: 304313980
	VISIT DATE: 02/10/2022

NARRATIVE

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Incidental Medical Services (IMS): Incidental Medical Services (IMS) policy was discussed. For IMS information 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 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: http://www.ada.gov/childqanda.htm.

Infant care: Applicant shall provide Infant care, all Infant items : diapers / wipes/ lotions and milk shall be provided by the parents. Mother's milk shall be labeled and stored appropriately. There is a changing table/ sleeping cribs and play mats for the infants. Applicant shall ensure the infants are supervised at all times during her care. LPA advised the Applicant to sleep infants where they can always be directly supervised and advised against sleeping infants in a separate room. The Applicant states the following as a supervision plan for infants: The infants will sleep where she will be providing supervision and they shall not be left unattended. LPA provided a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. Online copy can be downloaded at: https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

Safe Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
LPA reviewed with applicant the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used if they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold

(Page-5)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

LIC809 (FAS) - (06/04)

Page: 5 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LEELARATNE, SUMUDU	FACILITY NUMBER: 304313980
	VISIT DATE: 02/10/2022

NARRATIVE

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LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

LPA reviewed and issued the Forms/Records to Keep in Your Family Child Care Home (LIC 311D) and provided the following forms: All the forms were provided to the Applicant during the Pre-Licensing inspection today. Following forms were discussed and given to the applicant:

Distributed and explained the following sample forms packet:
Children Records: LIC: 700 Identification And Emergency Information, LIC 995E Caregiver Background Check Process, 995A Notification of Parent’s Rights, 627 Consent For Emergency Medical Treatment, 613A Personal Rights, LIC282 Affidavit Regarding Liability Insurance, LIC9150 Parent Notification, Additional Children in Care.
Facility Records: LIC9149 Property Owner/Landlord Consent, PUB 394 Notification of Parents Rights, LIC 9040 Facility Roster, LIC6101A Emergency Disaster Plan, LIC9148 Earthquake Preparedness Checklist, LIC 624 Unusual Incident/Injury Report.
Staff Records: LIC 508 Criminal Record Statement, LIC 501 Personnel Record, LIC 503 Health Screening/TB, LIC9052 Employee Rights, LIC9108 Statement Acknowledging Requirement to Report Child Abuse, LIC 9163 Request for LIVESCAN, LIC9188 Criminal Record Exemption Transfer Request, LIC 9182 Criminal Background Clearance Transfer Request, MMR, TDAP, FLU, Mandated Reporter Training Certificate.
OTHER INFORMATION AND FORMS PROVIDED: Capacity Handout for a Small Family Child Care Home. LPA explained the age requirements for the enrolled children ensuring that when there are 8 children, at least one child is enrolled in Kindergarten or 6 years old, to be in compliance with Title 22 requirements.

LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment. (Page-6)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

LIC809 (FAS) - (06/04)

Page: 6 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LEELARATNE, SUMUDU	FACILITY NUMBER: 304313980
	VISIT DATE: 02/10/2022

NARRATIVE

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Safe Sleep

LPA discussed the safe sleep regulations with Applicant Ms.Leelaratne, Sumudu 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 Applicant Ms. Leelaratne, Sumudu 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.

Subscribe to CCLD important information

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication..

The facility at the time of Pre-licensing inspection is not in compliance for a (Small Family Child Care Home) with Title 22 Regulations. License shall be issued upon receiving the following corrections within the next 3 weeks. A follow up Pre-Licensing inspection shall be conducted.

1) Installation of a child safety lock on the Spa cover in the back yard.
2) Install fencing on the sides of the covered patio making the side yards and part of back yard inaccessible to children.
3) Set up the back yard for outdoor activities.
4) Rose plant on the right side of the entrance door needs a safety barrier due to spikes on it.

Exit interview conducted and report was reviewed with the Applicant Ms. Leelaratne, Sumudu.

Appeal rights were presented.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

LIC809 (FAS) - (06/04)

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