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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334841732
Report Date: 01/09/2023
Date Signed: 01/09/2023 10:51:27 AM

Document Has Been Signed on 01/09/2023 10:51 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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:JAYASEKERA FAMILY CHILD CAREFACILITY NUMBER:
334841732
ADMINISTRATOR:JAYASEKERA, SHIRANIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 427-5241
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 6DATE:
01/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:Shirani Jayasekera, LicenseeTIME COMPLETED:
10:55 AM
NARRATIVE
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On date and time listed, Licensing Program Analyst (LPA) Elyse Jones arrived at the facility to conduct an annual inspection. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:
Normal days and hours of operation are: Monday-Friday 7:00AM-6:00PM
OFF-LIMIT AREAS INCLUDE: All of upstairs, Downstairs Closet, Garage
The facility is operating within the licensed capacity and appropriate ratios
· Appropriate supervision provided during this inspection
· A working telephone is present and current number on file
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.
· Fireplace is properly screened to prevent access by children
· All hazardous items are stored inaccessible to children
· Toxins are locked
· Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· Stairs are barricaded
· Verification of control of property on file
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Mandated Reporter Training completed on 9-19-2022
· Pediatric CPR and First Aid Card expires on 8-2024
· Health & Safety Certificate - completed on 7-8-2012
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2023
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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: JAYASEKERA FAMILY CHILD CARE
FACILITY NUMBER: 334841732
VISIT DATE: 01/09/2023
NARRATIVE
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· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Clean, safe and age appropriate toys
· Current roster on file
· Documentation of fire and disaster drills on file – Last drill conducted on 10-12-2022
· Children’s records are complete
· Employee’s records are NOT complete
· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
· Resident and/or staff records reviewed on 1-9-2023 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.
· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov
- LPA discussed the safe sleep regulations with Shirani Jayasekera, 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 Shirani Jayasekera, 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.

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

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023
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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: JAYASEKERA FAMILY CHILD CARE
FACILITY NUMBER: 334841732
VISIT DATE: 01/09/2023
NARRATIVE
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- Shirani Jayasekera, 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.

- Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.



- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

See LIC809-D for cited deficiencies.

Shirani Jayasekera, Licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

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.

Exit interview conducted and report was reviewed with Shirani Jayasekera, Licensee

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2023 10:51 AM - It Cannot Be Edited


Created By: Elyse Jones On 01/09/2023 at 10:11 AM
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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: JAYASEKERA FAMILY CHILD CARE
FACILITY NUMBER: 334841732

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102369(b)(9)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses an potential Health, Safety & Personal Rights risk to the children in care. S1 did not have proof of current TB clearance on file during inspection.
Regulation states: Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.
POC Due Date: 01/30/2023
Plan of Correction
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Licensee agrees to submit proof of TB clearance for S1 to the Department on or by POC due date. Licensee understands all adults around the children in care are required to have a TB clearance available for review.
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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2023 10:51 AM - It Cannot Be Edited


Created By: Elyse Jones On 01/09/2023 at 10:17 AM
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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: JAYASEKERA FAMILY CHILD CARE
FACILITY NUMBER: 334841732

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses an potential Health, Safety & Personal Rights risk to the children in care. S1 did not have proof of MMR vaccine on file during inspection.
POC Due Date: 01/30/2023
Plan of Correction
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Licensee agrees to submit proof of vaccine for S1 to the Department on or by POC due date. Licensee understands all adults providing care are required to have DTap (AND) MMR.
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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2023


LIC809 (FAS) - (06/04)
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