197403129-5-17-2022-30-CC-JLAO-CEHRA2-20220517125025

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197403129
Report Date: 05/17/2022
Date Signed: 05/17/2022 12:50:37 PM

Document Has Been Signed on 05/17/2022 12:50 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	KALUWAHEWA FAMILY DAY CARE		FACILITY NUMBER:	197403129
ADMINISTRATOR:	KALUWAHEWA, SHIYAMA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 715-9909
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91303
CAPACITY:	14	CENSUS: 0	DATE:	05/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Shiyama		TIME COMPLETED:	01:15 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 5/17/2022 Program Analyst (LPA), Judy Laureano conducted an unannounced Annual Required Inspection and was met by Shiyama Kaluwahewa. Days and hours of operation are 7:00 a.m. to 5:30 p.m., Monday through Sunday. Currently applicant does not have any children enrolled for Saturday or Sunday care. LPA toured the home inside and outside and a census was taken; no children were present during today’s inspections. Current facility was sketch reviewed, and Licensee confirmed that they den and enclosed patio room is used for the day care. Applicant confirmed children nap in the den area and weather permitted, children will eat in the enclosed patio and/or den area. The following areas are currently OFF LIMITS: the kitchen, bedroom 1, living room and dining room in the first floor and bedroom 2, bedroom 3, bedroom 4 and bathroom 2 in the second floor. LPA observed a attached garage that is OFF LIMITS. LPA observed safety gates in the kitchen area, living room area and at the bottom on the staircase, making the attached garage and 2nd floor inaccessible to the children in care. The bathroom that children use is the bathroom located outside the den area. LPA inspected and observed a safety latch in the sink cabinet. The den was inspected and LPA observed a fireplace made inaccessible by a screen and glass door. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible; locked in the kitchen sink cabinet.

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: KALUWAHEWA FAMILY DAY CARE	FACILITY NUMBER: 197403129
	VISIT DATE: 05/17/2022

NARRATIVE

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There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. Stairs are fenced or barricaded when children under age 5 years old are present. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (818) 715-9909.

There are currently no infants in care. Licensee confirmed she has only 3 children enrolled in the program. Licensee is available to care for infants. LPA discussed Safe Sleep Regulations with licensee and will email regulations for reference. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being
maintained.

LPA reviewed a sample of children’s files and observed files were incomplete and a Technical Advisory was issued. Licensee’s Mandated Reporter Training was not available for review. Licensee agrees to complete online training and submit proof of completion by 5/27/2022. Licensee’s pediatric CPR/First Aid expired on 12/1/2020, licensee agrees to submit proof of completion and/or registration of class by 5/27/2022. A review of records

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: KALUWAHEWA FAMILY DAY CARE	FACILITY NUMBER: 197403129
	VISIT DATE: 05/17/2022

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was not available and licensee was given a technical advisory and will submit proof to LPA via email by 5/27/2022- immunization records for MMR and Tdapt and influenza/flu.
All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

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/inspection-process.

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.

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 informed 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.

A notice of site visit was given and must remain posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Shiyama Kaluwaha.
Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D) Licensee was provided a copy of appeal rights.

SUPERVISOR'S NAME: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/17/2022 12:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: KALUWAHEWA FAMILY DAY CARE	FACILITY NUMBER: 197403129
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in completing the Mandated Reporter Training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2022
	Plan of Correction
1 2 3 4	Licensee agreeds to complete the training and submit online completion via email to LPA .

Type B

Section Cited

HSC

1597.622(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above in being able to provide proof immunization: Tdapt, MMR and Flu which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2022
	Plan of Correction
1 2 3 4	Licensee plans to submit proof of immunization to LPA by due date.

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: Claudia Escobedo	TELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Judy Laureano	TELEPHONE: (424) 301-3060
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC809 (FAS) - (06/04)

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