198017986-7-15-2020-33-CC-BBEL-BRJUQP-20200715154729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198017986
Report Date: 07/14/2020
Date Signed: 07/15/2020 03:47:39 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:	KARUNARATNE, DEEPANI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(626) 221-6485
CITY:	POMONA	STATE: CA	ZIP CODE:	91766
CAPACITY:	14	CENSUS: 1	DATE:	07/14/2020
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Licensee Deepani Karunaratne		TIME COMPLETED:	05:00 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	Licensing Program Analyst (LPA) Emiko Bell contacted the facility on 07/14/20 via FaceTime on the telephone due to COVID-19 and precautionary measures in order to conduct an announced Case management-licensee initiated inspection at the request of the licensee. The purpose of the inspection was to inspect bedroom #1 and the left gate entrance of the house. Census: There was one other adult and one child present. Prior to today's inspection, bedroom #1 was designated as an off-limits room. Licensee requested the inspection because she wants to use bedroom #1 as a nap room to ensure three feet head-to-toe spacing between children during nap time. In addition, licensee requested that the left side gate area be inspected so that parents may use this gate to go directly to the backyard at pick up time instead of having to enter the daycare room to then go to the backyard (as an extra precautionary measure). During the inspection, licensee placed electrical outlet covers in the four unused, unprotected electrical outlets observed in bedroom #1 and showed LPA the distance in the bedroom between the bed, the crib and the play pen. Licensee then went outside and showed LPA the side yard from the gate. Page 1/2

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2020

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: 07/14/2020

NARRATIVE

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Prior to approval of the use of bedroom #1 and of the left side gate, the following corrections will need to be made:

1. Bedroom #1, licensee would have to ensure at least three feet apart between the bed and the play pen, and the bed and the crib. (The bed and the crib were three feet apart and the crib and the play pen were six feet apart, but the bed and the play pen were less than three feet apart.)
2. The side yard: the pieces of wood need to be removed from the side yard
3. The air-conditioning unit will need to be rendered inaccessible.

An exit phone interview has been conducted with Licensee Deepani Karunaratne. This report has been signed by LPA Bell.

This report will be scanned via e-mail to Licensee Karunaratne, who understands that an electronic “Read Receipt” and/or confirmation of receipt of the e-mail confirms receipt of the report and constitutes an electronic signature.

A hard copy of this report has been placed in today’s mail and Licensee Karunaratne agrees to sign the bottom of each page of the 809 and return the originals to LPA Bell in-person or via U.S. Mail.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2020

LIC809 (FAS) - (06/04)

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