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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846424
Report Date: 08/08/2025
Date Signed: 08/08/2025 11:19:51 AM

Document Has Been Signed on 08/08/2025 11:19 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:SIRIWARDENA FAMILY CHILD CAREFACILITY NUMBER:
364846424
ADMINISTRATOR/
DIRECTOR:		SIRIWARDENA, WELMILLAGEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(424) 200-9006
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 3DATE:
08/08/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Welmillage Siriwardena, licnesee TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Aman Lama arrived at the facility to conduct an annual inspection. Upon arrival, LPA was met with licensee, Welmillage Siriwardena. Licensee granted LPA access to the home, where LPA was met with 3 children, 1 assistant and licensees own children, over 10 years of age. LPA toured the indoor and outdoor areas of the home. The following was observed and/or discussed:
Licensee is reminded to update facility sketch form, LIC999 with updates showing the “Family Room” on-limits to the children.
DAYS AND HOURS OF OPERATION ARE: Monday-Sunday, 23/7.
OFF-LIMIT AREAS INCLUDE: Kitchen, all bedrooms, garage, and backyard, excluding the porch.

· A working telephone is present and current phone number is on file.

· Appropriate fire extinguisher was observed, smoke& carbon monoxide detector were in working order.

· LPA did not observe any hazards accessible to daycare child(ren).

· Licensee stated there are no guns/weapons currently kept in the home. Should licensee choose to keep any guns/weapons in the home, all guns, weapons & ammunition must be key locked separately, made inaccessible & must remain in compliance with Title 22 Regulations.

· LPA observed appropriate postings in the home.

· Licensee provided an updated Mandated Reporter Training Certificate, which expires: 02/08/27.

· Pediatric CPR and First Aid Card for licensee and assistant expires: 09/26

NAME OF LICENSING PROGRAM MANAGER: Gilbert Sena
NAME OF LICENSING PROGRAM ANALYST: Aman Lama
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2025
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SIRIWARDENA FAMILY CHILD CARE
FACILITY NUMBER: 364846424
VISIT DATE: 08/08/2025
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·Bodies of water were not observed on the property during today’s inspection. Licensee is reminded that all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly fenced per Title 22 Regulations. The Department must be notified before and after installation of any of the above types of bodies of water. In addition, all wading pools or similar products must be emptied immediately after use and stored in an upright position.

· LPA observed Clean, safe and age appropriate toys available for children.

· Documentation of last fire/disaster drill indicated as last conducted: 04/07/25.

· 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

· LPA discussed Resident and/or staff records, and indicated that all adults who require caregiver background checks must receive all required clearances or exemptions. LPA provided the facility representative with a livescan form as well as a list of documentation needed for an adult assistant.

· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations862@dss.ca.gov

-Although licensee does not currently have any infants, LPA discussed the safe sleep regulations with 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 reminded the 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 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/.

NAME OF LICENSING PROGRAM MANAGER: Gilbert Sena
NAME OF LICENSING PROGRAM ANALYST: Aman Lama
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SIRIWARDENA FAMILY CHILD CARE
FACILITY NUMBER: 364846424
VISIT DATE: 08/08/2025
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- Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

- To receive Provider Information Notices (PINs), 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”. You can add your email address and choose which program(s) to receive PINs for.



- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at: 951-782-4200.

Licensee was 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.

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

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

Exit interview conducted and report was reviewed with the licensee, Welmillage Sirwardena.
NAME OF LICENSING PROGRAM MANAGER: Gilbert Sena
NAME OF LICENSING PROGRAM ANALYST: Aman Lama
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC809 (FAS) - (06/04)
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