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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197413585
Report Date: 10/16/2024
Date Signed: 10/16/2024 01:50:44 PM


Document Has Been Signed on 10/16/2024 01:50 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:NANAYAKKARA FAMILY CHILD CAREFACILITY NUMBER:
197413585
ADMINISTRATOR:NANAYAKKARA, REENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 704-7617
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:14CENSUS: 7DATE:
10/16/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Reena NanayakkaraTIME COMPLETED:
02:05 PM
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Licensing Program Analyst’s (LPA’s) Tatiana Bickham and Dawn Dowling conducted an unannounced annual required inspection at the above facility on October 16, 2024 at 09:00 am. Upon arrival, LPA’s disclosed the purpose of the inspection and met with Renna Nanayakkara Licenses, who guided LPA’s on a tour of the facility. Also present was Licensee’s Spouse and Son. Spouse is Licensee’s Assistant. There were 7 day care children present during today’s inspection. Per Licensee, there are currently seven children enrolled. Facility capacity is in compliance for a large Family Child Care Home. Hours of operation are Mon-Fri 7:00 AM – 5:30 PM.

LPA’s toured the home inside and outside. This is a one-story home which consists of 5 bedrooms, 2 bathrooms, kitchen, dining room, living room, laundry room, detached garage, front yard and backyard (fenced).



Per Licensee, areas off limits to children and parents include: 3 Bedrooms, 1 Bathroom, Kitchen, Dining Room, Laundry room, Front yard and detached garage.

Per Licensee, areas that are accessible to children include: 2 Bedrooms located at the rear of the home, 1 bathroom and backyard. The bathroom that the children use is in the rear bedroom.

Food is provided by Licensee. Licensee was reminded if children bring food from home, it must be labeled with the child’s name and properly stored or refrigerated.

Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption.

SUPERVISOR'S NAME: Raul NavarroTELEPHONE: (424) -30-3072
LICENSING EVALUATOR NAME: Tatiana BickhamTELEPHONE: (424) 301-3023
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
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 8


Document Has Been Signed on 10/16/2024 01:50 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: NANAYAKKARA FAMILY CHILD CARE
FACILITY NUMBER: 197413585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(d)(1)
Operation of A Family Child Care Home
(d) The home shall provide safe toys, play equipment and materials. (1) Fixtures, furniture, and equipment that have been banned or recalled by the United States Consumer Product Safety Commission shall not be used for children in care or accessible to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2024
Plan of Correction
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At 9:35 AM LPA's observed a baby Exersaucer in the assigned child area. At 09:40 am the assistant removed the Exersaucer from the room and stored in garage not accessisble to children.
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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Licensee will provide proof of fire extinguisher being services or proof of purchase.
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: Raul NavarroTELEPHONE: (424) -30-3072
LICENSING EVALUATOR NAME: Tatiana BickhamTELEPHONE: (424) 301-3023
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 01:50 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: NANAYAKKARA FAMILY CHILD CARE
FACILITY NUMBER: 197413585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview and record review the licensee did not comply with the section cited above 3 out of 3 persons which poses a potential health, safety or personal rights risk to persons in care
POC Due Date: 10/21/2024
Plan of Correction
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Licensee will provide proff of 15 minute safe sleep for all infants.
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: Raul NavarroTELEPHONE: (424) -30-3072
LICENSING EVALUATOR NAME: Tatiana BickhamTELEPHONE: (424) 301-3023
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 01:50 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: NANAYAKKARA FAMILY CHILD CARE
FACILITY NUMBER: 197413585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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Licensee will provide complete records for two children. Licensee will provide missing immunization records for 1 child.
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: Raul NavarroTELEPHONE: (424) -30-3072
LICENSING EVALUATOR NAME: Tatiana BickhamTELEPHONE: (424) 301-3023
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NANAYAKKARA FAMILY CHILD CARE
FACILITY NUMBER: 197413585
VISIT DATE: 10/16/2024
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All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection:

LPA’s reviewed required posted documentation for Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted on October 02,2024.

Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher was not serviced or purchased within the last year. The home maintains telephone service via landline and cell phone. The home is observed to be clean and orderly. There are toys and other age-appropriate materials available for children. LPA’s observed that detergents, cleaning compounds and medication are stored in laundry room, inaccessible to children. Licensee states that there are no poisons stored in the home and understands that all poisons must be lock, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in the back room, away from the other children. Per Licensee there are no firearms or weapons stored in the home.

Infant Care: Currently licensee cares for three infants. LPA’s observed three play yard visible in room used for day care. Napping equipment does not block entrances or exits. Infant mattresses were observed to be firm with tightly fitted sheets. LPA’s did not observe loose object, bumpers, objects hanging, or objects attached to the play yards. Per licensee wet or soiled sheets are removed and given to parents to wash. Each infant has their own play yard and bedding. Bedding is washed every week by parents. LPA’s informed licensee of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, and provided PIN 20-24-CCP. Licensee states the following sleep supervision plan for infants: Per Licensee, they stay in the room while they are napping.

Overnight Care: Per Licensee overnight care is not provided.

Currently, children are using the back yard for outdoor play. The outdoor play area was observed to be fenced. LPA’s observed that the outdoor yard has toys and other materials for children to play with. LPA’s did not observe any objects that could be hazardous to children in care. There are no pools or spas, or other bodies of water.


SUPERVISOR'S NAME: Raul NavarroTELEPHONE: (424) -30-3072
LICENSING EVALUATOR NAME: Tatiana BickhamTELEPHONE: (424) 301-3023
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NANAYAKKARA FAMILY CHILD CARE
FACILITY NUMBER: 197413585
VISIT DATE: 10/16/2024
NARRATIVE
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Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization's Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months). During file review Licensee was missing 2 out of 7 children were missing files. Licensee was also missing 3 out of 5 Immunization records. Licensee received proof of Immunization for 2 children via email.

Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunization's against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate expired 10/15/2024, per Licensee Assistant they will take the training this weekend.

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful, and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

Incidental Medical Services (IMS):
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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

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.

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SUPERVISOR'S NAME: Raul NavarroTELEPHONE: (424) -30-3072
LICENSING EVALUATOR NAME: Tatiana BickhamTELEPHONE: (424) 301-3023
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 7 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: NANAYAKKARA FAMILY CHILD CARE
FACILITY NUMBER: 197413585
VISIT DATE: 10/16/2024
NARRATIVE
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Licensee was reminded of their responsibility to report suspected child abuse. Mandatory Forms for the children’s files and provider’s files were discussed. Licensee was made aware that state law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category. Licensee was reminded that all infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome), and that the Provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome. 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. Licensee was also reminded that only children eating may be in highchairs and that car seats are utilized only for transportation.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

The licensee was advised the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, (Type A violation), a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. The applicant was made aware that a licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment.

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

Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

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

SUPERVISOR'S NAME: Raul NavarroTELEPHONE: (424) -30-3072
LICENSING EVALUATOR NAME: Tatiana BickhamTELEPHONE: (424) 301-3023
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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