198019180-10-18-2022-54-CC-MAYA-CKBPPM-20221018112946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198019180
Report Date: 10/18/2022
Date Signed: 10/18/2022 11:30:07 AM

Document Has Been Signed on 10/18/2022 11:30 AM - It Cannot Be Edited

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:	SUBASINGHE FAMILY CHILD CARE		FACILITY NUMBER:	198019180
ADMINISTRATOR:	KALYANI SUBASINGHE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 316-6185
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90712
CAPACITY:	14	CENSUS: 5	DATE:	10/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee, Kalyani Subasinghe		TIME COMPLETED:	11:40 AM

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	On October 18, 2022 at 9:00 AM, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced inspection at the facility noted above and met with Licensee, Kalyani Subasinghe. The purpose of the inspection was to conduct the Required - 1 Year inspection. The operating hours of the facility is Monday through Friday from 6:00 AM to 6:00 PM. Entrance Checklist (LIC 126) was provided to the Licensee upon arrival. Individuals residing in the home were discussed and noted. At the time of the inspection, 5 children were present. All areas identified on the facility sketch were inspected. This facility is a single family home that consists of three (3) bedrooms, two (2) bathrooms, living room, dining room, kitchen, detached garage, and fenced backyard. Areas that are accessible to children include: one (1) bathroom, living room, dining room, and fenced backyard. Per Licensee, the children utilize the fenced backyard for outdoor activity. Areas off-limits to children include: 3 bedrooms, 1 bathroom, kitchen, and detached garage. LPA observed the bedroom and bathroom doors closed with child safety knobs installed, making the areas inaccessible to children in care. LPA observed a child safety gate installed on the door way leading into the kitchen, making the area inaccessible to children in care. Licensee stated that she provides direct supervision while she walks the children through the kitchen to access the backyard. The Licensee was advised that off-limit areas must be made inaccessible during operating hours. The following documents were posted in a prominent, publicly accessible area: Facility License, Notification of Parents' Rights (PUB 394), and Earthquake Preparedness (LIC 9148). Licensee has a current Facility Roster (LIC 9040). Licensee also has verification of disaster and fire drills. The last drill was conducted on 10/1/2022.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SUBASINGHE FAMILY CHILD CARE	FACILITY NUMBER: 198019180
	VISIT DATE: 10/18/2022

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Areas used by children were inspected for safety, comfort, heating, cleanliness and telephone service. LPA observed a wall heater located in the living room and hallway that is barricaded, making it inaccessible to children in care. The home does not have any fireplaces. Detergents, cleaning compounds and medicines were made inaccessible to children. Per Licensee, there are no poisons kept in the home. Licensee was advised that if any poisons are purchased, it is required to be locked with a key or combination lock.

Per Licensee, there are no firearms and/or weapons on the premises. The Licensee has 3 dogs that were kept in an off-limit bedroom at the time of the inspection. LPA advised Licensee that best practice is to keep pets isolated from children in care. LPA observed age appropriate toys and napping equipment for children. LPA observed electrical outlet covers installed in the child care areas.

LPA observed the required fire extinguisher (2A-10BC) that is fully charged and was last serviced on 10/22/2021. Licensee was reminded to have the fire extinguisher serviced yearly. Smoke detector and carbon monoxide detector was tested and is operable. First Aid kit and emergency supplies are available and kept in the hallway. Licensee was reminded that food that is brought from the child's home shall be labeled with the child’s name and properly stored or refrigerated.

LPA conducted a record review of five (5) children's records and the Licensee's record. Based on the record review, the children's records were incomplete. Child (C1) did not have their immunization record and Consent for Emergency Medical Treatment (LIC 627) available for review. Child (C2) did not have the LIC 627 and Notification of Parents' Rights available for review. Child (C3) did not have the LIC 995A available for review. Child (C4) did not have the LIC 627 available for review. Child (C5) did not have the Affidavit Regarding Liability Insurance (LIC 282), immunization record, Identification and Emergency Information (LIC 700), LIC 627, LIC 995A, and Individual Infant Sleeping Plan (LIC 9227) available for review. Licensee did not have verification of Safe Sleep Log available for review for C1, C4, and C5.

Licensee has proof of immunization against measles, pertussis, and a TB clearance. Licensee has a decline statement on record for influenza. Licensee has a valid Pediatric First Aid and CPR certification (expires 04/2024). Licensee completed the required Preventative Health and Safety Practices on 7/29/2016 and Mandated Reporter Training (AB 1207) on 3/20/2022. Licensee was advised that the Mandated Reporter training (AB 1207) must be completed every 2 years and is available at www.mandatedreporterca.com.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SUBASINGHE FAMILY CHILD CARE	FACILITY NUMBER: 198019180
	VISIT DATE: 10/18/2022

NARRATIVE

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LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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 was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PINs), Program Quarterly Update Newsletters and other important information communication platforms.

LPA provided assistance to the Licensee on how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: SUBASINGHE FAMILY CHILD CARE	FACILITY NUMBER: 198019180
	VISIT DATE: 10/18/2022

NARRATIVE

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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Deficiencies were cited during today's inspection (refer to deficiency pages).

A Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Licensee, Kalyani Subasinghe.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/18/2022 11:30 AM - It Cannot Be Edited

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: SUBASINGHE FAMILY CHILD CARE	FACILITY NUMBER: 198019180
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(7)

Operation of A Family Child Care Home

(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. 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 4 out of 5 children's records (C1, C2, C4, and C5) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/18/2022
	Plan of Correction
1 2 3 4	Licensee will e-mail LPA the completed Consent for Emergency Medical Treatment (LIC 627) for child (C1), C2, C4, and C5 by 11/18/2022. Licensee will also e-mail LPA the completed Identification and Emergency Information (LIC 700) for C5 by 11/18/2022.

Type B

Section Cited

CCR

102418(g)

Immunizations

(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. 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 2 out of 5 children's records (C1 and C5) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/18/2022
	Plan of Correction
1 2 3 4	Licensee will e-mail LPA the immunization records for child (C1) and C5 by 11/18/2022.

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) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/18/2022 11:30 AM - It Cannot Be Edited

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: SUBASINGHE FAMILY CHILD CARE	FACILITY NUMBER: 198019180
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)(1)

Admission Procedures and Authorized Representatives Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05). 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 3 out of 5 children's records (C2, C3, and C5) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/18/2022
	Plan of Correction
1 2 3 4	Licensee will e-mail LPA the completed Notification of Parents' Rights (LIC 995A) for child (C2), C3, and C5 by 11/18/2022.

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) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/18/2022 11:30 AM - It Cannot Be Edited

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: SUBASINGHE FAMILY CHILD CARE	FACILITY NUMBER: 198019180
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(m)(3)

Operation of A Family Child Care Home

(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state. 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 1 out of 5 children's records (C5) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/18/2022
	Plan of Correction
1 2 3 4	Licensee will e-mail LPA the completed Affidavit Regarding Liability Insurance (LIC 282) for child (C5) by 11/18/2022.

Type B

Section Cited

CCR

102425(c)(2)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review. 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 1 of the children's records (C5) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/18/2022
	Plan of Correction
1 2 3 4	Licensee will e-mail LPA the completed Individual Infant Sleeping Plan (LIC 9227) for child (C5) by 11/18/2022.

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) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC809 (FAS) - (06/04)

Page: 7 of 8

Document Has Been Signed on 10/18/2022 11:30 AM - It Cannot Be Edited

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: SUBASINGHE FAMILY CHILD CARE	FACILITY NUMBER: 198019180
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: 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 3 of the children's records (C1, C4, and C5) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/18/2022
	Plan of Correction
1 2 3 4	Licensee will e-mail LPA at least one week of the 15-minute physical checks for the children (C1, C4, and C5) napping (Safe Sleep Log).

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: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique Ayala	TELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC809 (FAS) - (06/04)

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