198013602-9-6-2019-54-CC-RNAO-BFRSF4-20190906134943

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198013602
Report Date: 09/06/2019
Date Signed: 09/06/2019 01:49:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	DE SILVA FAMILY CHILD CARE		FACILITY NUMBER:	198013602
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 3	DATE:	09/06/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	12:54 PM
MET WITH:	Shiromi De Silva		TIME COMPLETED:	01:55 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	Licensing Program Analyst (LPA) Raul Navarro conducted an unannounced random annual inspection. LPA met with Licensee Shiromi De Silva who guided this LPA on a tour of the facility. Also present was Licensee's spouse. There were three children present during today’s inspection. Licensee states that there are currently seven children enrolled. The children's roster was reviewed and is current. Disaster drill log was also available during today’s inspection. Last drill conducted on April 2019. This is a one story home which consists of three bedrooms and two bathrooms. Areas used by the children include the playroom, office/napping room, one bathroom, and back yard. Per Licensee, areas off limits to children and parents include: three bedrooms, one bathroom, living room, kitchen, front yard and garage. Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for the safety of the children. There is a working telephone maintained in the home. Family members residing in the home are two adults (criminal record clearances on file). Licensee has a pet dog. Detergents, cleaning compounds, medications, and other items which can pose a danger to children are inaccessible. The Licensee states that there are no poisons in the home. Per Licensee, there are no weapons or firearms in the home. LPA did not observe any bodies of water on the premises. There are safe toys, play equipment and materials observed for children. Emergency Disaster Plan was posted at the time of inspection. Children’s records were reviewed to ensure that each child has an Identification and Emergency form. The valve on the required 2A 10BC fire extinguisher indicates fully charged, however, it was last purchased over a year ago. Smoke and carbon monoxide detectors are in operable condition. The Licensees have current Pediatric First Aid and CPR, which will expire on 06/2021. Report continues- Page 1 of 3

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Raul Navarro	TELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2019

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: DE SILVA FAMILY CHILD CARE	FACILITY NUMBER: 198013602
	VISIT DATE: 09/06/2019

NARRATIVE

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Proof of immunization against influenza, pertussis, and measles for the Licensee was readily available during today’s inspection. The Licensee has also taken the Mandated Reporter Training.

The following was discussed: Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

Rooms that are off-limits need to be made inaccessible during operating hours. No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility. Effective January 1, 2010, licensees of family child care homes are required to ensure that at least one staff member with current training in pediatric first aid and pediatric CPR is on site at all times when children are present.

Mandatory Forms for the children’s files and staff files, requirements for fire drills, earthquake drills and documentation were discussed. Role and responsibilities of being a Mandated Reporter were reviewed. The Licensee was advised how to access forms and Regulations online at www.ccld.ca.gov. Licensee was made aware that it is his/her responsibility to know the regulations as well as anyone who assists in providing care.

The Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Sudden Infant Death Syndrome (SIDS) and Never-Shake-a-Baby were discussed.

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 Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPA issued the Confidential Names List (LIC 811) to the licensee during this visit. The Confidential Names List documents the children’s files that were reviewed during this inspection.

Report continues- Page 2 of 3

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Raul Navarro	TELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2019

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: DE SILVA FAMILY CHILD CARE	FACILITY NUMBER: 198013602
	VISIT DATE: 09/06/2019

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The deficiency listed on the following page were observed by the LPA and is being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D. The deficiency that are being cited need to be cleared to protect the children’s health & safety.

Exit interview was conducted with Licensee Shiromi De Silva. The Licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these forms.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site inspection by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Report ends- Page 3 of 3

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Raul Navarro	TELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2019

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: DE SILVA FAMILY CHILD CARE	FACILITY NUMBER: 198013602
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/06/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/20/2019 Section Cited	1 2 3 4 5 6 7	Operation of a Family Child Care Home- The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal. This requirement was not met as evidenced through file review. Per Licensee the Fire extinguisher was purchased over a year ago and has not been serviced. This is a potential
	8 9 10 11 12 13 14	risk to the health and safety of the children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Karen Chambers	TELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Raul Navarro	TELEPHONE: 323-981-3388
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2019

LIC809 (FAS) - (06/04)

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