364846424-8-28-2023-09-CC-BRSA-CV5U9Z-20230828152359

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364846424
Report Date: 08/28/2023
Date Signed: 08/28/2023 03:24:05 PM

Document Has Been Signed on 08/28/2023 03:24 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	SIRIWARDENA SELLAPPERUMA FAMILY CHILD CARE		FACILITY NUMBER:	364846424
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	08/28/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Wellmillage Siriwardena and Joseph Sellapperuma		TIME COMPLETED:	01:45 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	On date and time listed, Licensing Program Analyst (LPA) Blanca Ruiz arrived at the facility to conduct a pre-licensing inspection. Present during this inspection were applicant(s),Wellmillage Siriwardena and Joseph Sellapperuma . LPA toured the facility, inside and out and the following was observed and/or discussed: Normal days and hours of operation are: Monday-Friday 6:00 a.m.-8:00 p.m. OFF-LIMIT AREAS INCLUDE: All bedrooms, laundry room and garage. Appropriate fire extinguisher, smoke detector and carbon monoxide detector are present and were tested by the applicant during this inspection. Fire extinguisher, smoke detector and carbon monoxide detector are in working order. · All hazardous items are inaccessible · Toxins locked · Applicants understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations. · Storage of poisons is inaccessible to children and locked · Verification of control of property on file (Grant Deed) · Facility Sketch and Emergency Disaster Plan are posted · Mandated Reporter Training completed 01/02/2023 · Pediatric CPR and First Aid Card – expires 07/16/2025 · Health & Safety Certificate - completed on 07/16/2023 · Applicants understands all bodies of water including ponds, above ground pools and spas, in-ground pools and 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.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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: SIRIWARDENA SELLAPPERUMA FAMILY CHILD CARE	FACILITY NUMBER: 364846424
	VISIT DATE: 08/28/2023

NARRATIVE

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In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position when not in use.
· Clean, safe and age appropriate toys
· There are no toxic plants observed at this time
·The Applicant 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 08/28/2023 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.
· The Applicant can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov

The following was discussed with the applicant(s):
- Pre-Licensing Visit Packet provided
- Failure to meet the posting requirements shall result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills to be conducted every six months
- Responsibilities of being a mandated reporter
- Responsibility to know the regulations for anyone providing care
- Inaccessibility of hazards must be constantly reassessed depending on the children in care
- Current facility’s phone numbers must always be on file with the licensing office
- Baby walkers, baby-bouncer, and walker-jumpers are prohibited (H&S 1500.86(a)(4))

LIC 311D was reviewed with applicant Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.
LPA discussed the safe sleep regulations with Wellmillage Siriwardena and Joseph Sellapperuma 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(s) Wellmillage Siriwardena and Joseph Sellapperuma 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.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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: SIRIWARDENA SELLAPPERUMA FAMILY CHILD CARE	FACILITY NUMBER: 364846424
	VISIT DATE: 08/28/2023

NARRATIVE

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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:
http://www.ada.gov/childqanda.htm Wellmillage Siriwardena and Joseph Sellapperuma reminded that all adults 18 and over living in the home, persons who provide 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 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.
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 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
Before licensure, the following needs to be corrected/completed:

- Applicants agrees to change the following door knobs ( lock and key):

1. Door knob leading to the laundry and garage.
2. Door knob leading to Master Bedroom.
3. Lock for Cabinet with Medication.

Once all corrections have been verified, the application for a Small Family Child Care Home will be submitted for approval with a maximum capacity of 6, or 8 with parent notification. Applicants advised that all corrections are due within 30 days or the application may be withdrawn.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

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