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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624323
Report Date: 08/04/2022
Date Signed: 08/04/2022 11:15:17 AM

Document Has Been Signed on 08/04/2022 11:15 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:ADVENTURE MONTESSORI S.T.E.A.M ACADEMY LLCFACILITY NUMBER:
343624323
ADMINISTRATOR:SITHUMINI S MILLAWABANDARAFACILITY TYPE:
830
ADDRESS:3541 N FREEWAY BLVD SUITE 100TELEPHONE:
(916) 370-6113
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/04/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sithumini (Situ) MillawabandaraTIME COMPLETED:
11:30 AM
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Application Specialist (AS) Alecia Sifuentes met with Applicant, Sithumini (Situ) Millawabandara for the purpose of an announced pre-licensing inspection. Applicant requests an infant license to serve 8 infant children from 12 months to two years of age. The program will operate Monday through Friday from 7:00 a.m. to 6:00 p.m. The fire clearance was granted and received on 7/27/2022. The facility will be providing breakfast, lunch, and snacks. Parents will provide formula, breast milk, and baby food for their children.

AS reviewed with applicant the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted. AS discussed the safe sleep regulations with applicant 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. AS also informed applicant 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.

INDOOR ACTIVITY SPACE:
There is one infant classroom. AS observed a sufficient amount of equipment, toys, tables, and chairs. There is no nap area. Applicant has requested a waiver. Applicant acknowledges there will be a maximum of 0 infants under 12 months old, due to available cribs. There is a first aid kit located in the kitchen. Medications will be stored in the kitchen cabinet. AS observed cleaning disinfectants are appropriately stored and inaccessible to children. Applicant stated there are no poisons or firearms on the premises. Applicant stated there will be a water pitcher and cups available in the classroom. AS observed a functional carbon monoxide detector in the classroom. AS observed a sign-in/sign-out binder.

Report continues on LIC809-C.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: ADVENTURE MONTESSORI S.T.E.A.M ACADEMY LLC
FACILITY NUMBER: 343624323
VISIT DATE: 08/04/2022
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AS measured the classroom. The total classroom space contains a total of 297 square feet, which will accommodate applicant's request for 8 infant children. There is one sink for the children, and a separate private restroom for the staff. AS observed a changing table within arm's reach of a sink. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Children who become ill during the day will be isolated in the office area and will use the staff restroom, if necessary.

OUTDOOR ACTIVITY SPACE:
There is one outdoor area on the property. The outdoor play area is fenced with a wrought iron fence that is at least four feet tall. Applicant has requested a Shared Outdoor Space Waiver. AS observed a sufficient amount of equipment and toys. There are no bodies of water on the premises. There are shaded areas supplied an overhang and one umbrella. Applicant stated that they plan to install a retractable canopy.

AS measured the outdoor activity space. The outdoor play area contains a total of 2,987.59 square feet, which will accommodate applicant's request for 8 infant children. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A 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)/ (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

AS discussed the following: 100% supervision is required at all times; personal rights; inspection authority; reporting requirements; staff to children ratios and capacity; staff qualifications; and maintaining buildings and grounds. AS discussed with Applicant any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within 10 working days.

Report continues on LIC809-C.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: ADVENTURE MONTESSORI S.T.E.A.M ACADEMY LLC
FACILITY NUMBER: 343624323
VISIT DATE: 08/04/2022
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Applicant was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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 Center. 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.

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.

Exit interview conducted and report was reviewed with the applicant, Sithumini Millawabandara.

AS will issue a provisional license that will expire in 90 days on 11/2/2022. Once the provisional is issued, the following items are to be submitted prior to expiration of the provisional license for final approval of license:

1. Remaining paperwork.
2. Final file review from Licensing Program Manager (LPM)
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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