198017986-3-17-2020-33-CC-BBEL-BMT5SN-20200317201301

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198017986
Report Date: 03/17/2020
Date Signed: 03/17/2020 08:13:21 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	KARUNARATNE FAMILY CHILD CARE		FACILITY NUMBER:	198017986
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 6	DATE:	03/17/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Licensee Deepani Karunaratne		TIME COMPLETED:	08:00 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	An unannounced Annual/Random (Case Management-Licensee-initiated) inspection was conducted on this date by Licensing Program Analyst (LPA) B. Emiko Bell. The purpose of the inspection is because Licensee is requesting an increase in capacity from a small (capacity 8) to a large (capacity 14). Licensee qualifies because she has been licensed at this residence since 05/30/17. Licensee's spouse is her designated assistant. Upon arrival, LPA was greeted and let into the residence by licensee, to whom the reason for the inspection was announced. There was one other adult present until 4:45 P.M. Census: Staff-child ratio was met. (See 812 for details.) Licensee's days and hours of operation are 24/7.06:00 P.M. This is a single-story, single family residence with four bedrooms and two bathrooms. All areas identified on the facility sketches were inspected in the following order: (indoors): the living room, the garage, bedroom #1, bathroom #2,bedroom #2, bedroom #3, bathroom #1, the kitchen, and bedroom #4 and then (outdoors): the backyard. The following areas have been designated as off-limits areas: the garage, bedrooms #1-3, and bathroom #1. All doors were either locked or had a doorknob handle cover on them, rendering them inaccessible.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2020

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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: KARUNARATNE FAMILY CHILD CARE	FACILITY NUMBER: 198017986
	VISIT DATE: 03/17/2020

NARRATIVE

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influenza declination for both her and her spouse.

As there are 10 children enrolled; five files were reviewed for the required forms as listed on the LIC 311D with Licensee. During record review, from 7:15-7:27 P.M., LPA noted that two of the five children's files were missing form LIC 9150 Parent Notification, Additional Children in Care. Licensee stated that she must have forgotten to provide their parents/guardians with the form.

Based on record review, licensee forgot to provide the parents of two (Child #1 and Child #5) of the five children whose files were reviewed today with the form LIC 9150 Parent Notification, Additional Children in Care. This poses a potential Health, Safety or Personal Rights risk to the children in care.

The capacity increase will be granted when the citation issued has been verified to have been corrected.

******During today's visit, the Confidential Names list was provided to the Licensee.*********

The Notice of Site Visit was posted by Licensee in LPA's presence. The Notice of Site Visit shall be posted for thirty (30) consecutive days. Failure to maintain posting as required will result in the issuance of a citation and the assessment of a $100 civil penalty.

An exit interview has been conducted with and a copy of this report has been signed by and provided to Licensee Deepani Karunaratne. Appeal Rights have been provided and explained to Licensee as well.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2020

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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: KARUNARATNE FAMILY CHILD CARE	FACILITY NUMBER: 198017986
	VISIT DATE: 03/17/2020

NARRATIVE

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Physical Plant: The residence was inspected for safety, comfort, cleanliness, telephone service (licensee only has a cell phone), heating and ventilation (there is central heating and air-conditioning), inaccessibility to poisons, detergents (kept in the garage), cleaning compounds (kept under the kitchen sink, which has a childproof latch,) medicine (which is kept in a kitchen drawer which has a childproof latch on it) and other hazardous items that can pose a danger to children.

Toys and napping equipment: There are age-appropriate toys and napping equipment on the premises. Licensee has one playpen, one crib (manufactured in 01/19 and meets CSPC CFR 1220), three mats, one mattress and one couch for the children to sleep on.

Parent Board: At 3:15 P.M., LPA observed that the Parent Board is posted on a wall in bedroom #4. As Licensee stated that she is no longer allowing parents to enter her residence through the door of bedroom #4, but only through the front door, LPA told Licensee that she would need to either have parents enter through bedroom #4 (as she stated that she did up until August 2019) or to move the Parent Board to a wall in the living room. Licensee decided to have parents enter through the door of bedroom #4 again and was verbally informing each of them in LPA's presence as they came to pick their children up. All required postings were observed (the license, the Notification of Parents Rights, the Emergency Disaster Plan.)

Pets: Licensee does not currently have any pets.

Fire safety: Licensee has a fire extinguisher, size 3-A:40-B:C, which is mounted on a wall in the kitchen. It was last serviced 01/20/20. Licensee keeps a fire drill log. The last fire drill was logged on 01/13/20 at 3:42 P.M. There are seven smoke detectors in the residence (one in each

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2020

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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: KARUNARATNE FAMILY CHILD CARE	FACILITY NUMBER: 198017986
	VISIT DATE: 03/17/2020

NARRATIVE

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bedroom and three in the hallway); all were tested and are operable. There are two carbon monoxide detectors on the premises; both are electric and are plugged into electrical outlets; both were tested and are operable.

Transportation: Licensee stated that she offers transportation. LPA was not able to inspect her vehicle because she stated that her adult son is driving it. Therefore, her vehicle was not inspected during today's visit.

Firearms: Licensee has firearms. See 812 for detail of storage.

Incidental Medical Services: 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

Licensee keeps one First Aid Kit in her bathroom and another in an emergency backpack which is kept in bedroom #4.

Paperwork: Licensee's roster was current and complete. Licensee and her spouse's Pediatric First Aid/CPR were issued by an EMSA-certified trainer and expire 06/20. Licensee and her spouse are both currently exempt from completing the Mandated Reporter Training, as English is not their primary language. Licensee provided verification of MMR and TDAP immunizations and

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2020

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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: KARUNARATNE FAMILY CHILD CARE	FACILITY NUMBER: 198017986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/27/2020 Section Cited	1 2 3 4 5 6 7	102416.5(b)(3)(C) STAFFING RATIO AND CAPACITY The licensee notifies each parent that the facility is caring for two additional schoolage children and that there may be up to seven or eight children in the home at one time.
	8 9 10 11 12 13 14	-This requirement is not met as evidenced by: Based on record review, licensee forgot to provide the parents of two (Child #1 and Child #5) of the five children whose files were reviewed today with the form LIC 9150 Parent Notification, Additional Children in Care. This poses a potential Health, Safety or Personal Rights risk to 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: Valarie Cook	TELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2020

LIC809 (FAS) - (06/04)

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