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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700033
Report Date: 05/19/2021
Date Signed: 05/19/2021 01:58:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:SILVA FAMILY CHILD CAREFACILITY NUMBER:
197700033
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 8DATE:
05/19/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Licensee Kumuduni SilvaTIME COMPLETED:
02:15 PM
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On May 19, 2021 at 12:28PM, Licensing Program Analyst (LPA) Brigitte Tsutaoka conducted a follow up inspection to verify the completion of the Plan of Correction (POC) generated from the citation issued May 18, 2021 and confirm Licensee's adult children obtained a fingerprint clearance. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee. Upon entry, LPA observed 8 children in care.

At 12:40 PM, Licensee provided LPA the completed Request for Live Scan Service (LIC9163) for both of her adult children with the bottom portion completed by the live scan agency with official stamp. Licensee also provided declaration during inspection.

On Tuesday, May 18, 2021, the Licensee was cited, and a plan of correction was due Wednesday, May 19, 2021 which has been corrected.

The facility was in compliance per Title 22 regulations, and civil penalties will not be cited today, May 19, 2021. An exit interview was conducted, a copy of this report and a notice of site visit was provided to the Licensee Kumuduni Silva. Appeal rights were provided and discussed with Licensee.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Brigitte TsutaokaTELEPHONE: (661) 202-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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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