197494386-11-16-2021-30-CC-AALA-C8TU7L-20211116142006

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197494386
Report Date: 11/16/2021
Date Signed: 11/16/2021 02:20:16 PM

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:	GOONETILLEKE FAMILY CHILD CARE		FACILITY NUMBER:	197494386
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 4	DATE:	11/16/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:14 AM
MET WITH:	Licensee: Lorna Goonetilleke		TIME COMPLETED:	02:30 PM

NARRATIVE

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On 11/16/21 at 11:14 am, Licensing Program Analyst (LPA) Antonio Almanza, conducted an unannounced Annual Required Inspection and was met by Licensee, Lorna Goonetilleke. Also present were Licensees Adult Daughter. Days and hours of operation are Monday to Friday 6:00 a.m. to 6:00 p.m.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed, and Licensee confirmed that the living room is used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of Safety Gate and Locked doors. There are no firearms or ammunition on the premises. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

The fireplace located in the Living room area and is blocked off. 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 818-383-0994.

There are currently infants in care. LPA discussed Safe Sleep Regulations with licensee. 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 (LIC9227) 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.

SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio Almanza	TELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

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: GOONETILLEKE FAMILY CHILD CARE	FACILITY NUMBER: 197494386
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that the Pediatric First Aid Certification Expired on 08/10/2021, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2021
	Plan of Correction
1 2 3 4	Licensee will provide LPA a copy of Pediatric First Aid Certification by 11/22/2021.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio Almanza	TELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

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: GOONETILLEKE FAMILY CHILD CARE	FACILITY NUMBER: 197494386
	VISIT DATE: 11/16/2021

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Licensee ensures that children in care are supervised 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 complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on 11/16/21. Licensee’s pediatric CPR/First Aid expired on 08/10/2019. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

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.

Incidental Medical Services (IMS) are currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

There is 1 deficiency being cited during today’s visit, Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, 102416(c) Please see LIC 809D. Licensee was provided a copy of appeal rights.

Upon receipt of a Type A violation, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. Child Care Parent Notification Requirements and a copy of LIC 9224 was given to licensee.

A copy of this report was explained and provided to Licensee Lorna Goonetilleke. This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Mary Ruiz	TELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Antonio Almanza	TELEPHONE: (424) 301-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

LIC809 (FAS) - (06/04)

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