198019361-9-9-2020-54-CC-MRIA-BTAMGZ-20200909093642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198019361
Report Date: 08/11/2020
Date Signed: 09/09/2020 09:36:56 AM

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:	KARIYAKARAWANA FAMILY CHILD CARE		FACILITY NUMBER:	198019361
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 4	DATE:	08/11/2020
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sangeetha Kariyakarawana, Licensee		TIME COMPLETED:	11:00 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 Tuesday, August 11, 2020 at 10:00 AM, Licensing Program Analyst (LPA) Mayra Rivera conducted a pre-licensing inspection to increase capacity via teleconference. This pre-licensing inspection conducted by LPA Rivera, due to COVID 19 and precautionary measures the inspection was conducted via teleconference using FaceTime. The teleconference was conducted with Licensee Sangeetha Kariyakarawana, who guided LPA Rivera on a tour of the facility. Family members residing in the home are licensee spouse Sujeewa Kariyakarawana and daughter Chirashri Kariyakarawana who were present and 4 toddlers during the pre-licensing inspection. Licensee stated currently has 4 children enrolled and current children's roster is available. The applicant is requesting for a capacity increase childcare home license. Operating hours will be Monday to Friday, 6:30 AM to 6:30 PM. All areas identified on the facility sketch were inspected. This facility is a two-story home that consists of four (4) bedrooms, three (3) bathrooms, kitchen, living room, front yard, backyard (fenced) and garage. Areas that are accessible to children include: 1 bedroom (daycare room), dining room, 1 bathroom located in the hallway next to daycare room (working toilet, paper towels, hand soap and running water available), and backyard. Per licensee, children will utilize the backyard (fenced) or children will be escorted to Glacier Park for outdoor play under 100 percent active supervision at all times for outdoor activity, and parents will be utilizing the front door for drop off /pick up. Areas off limits to children include: all upstairs rooms three (3) bedrooms, two (2) bathrooms; kitchen and garage. The licensee was advised that areas that are off limits must be made inaccessible during operating hours.

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: KARIYAKARAWANA FAMILY CHILD CARE	FACILITY NUMBER: 198019361
	VISIT DATE: 08/11/2020

NARRATIVE

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Areas that will be used by the children were inspected for safety, comfort, cleanliness, telephone service, ventilation and heating (central). Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are placed in the garage and are inaccessible to children. LPA Rivera observed child proof locks in place to make cabinets inaccessible and a safety gate to prevent children from going up stairs. The Licensee states that there are no poisons in the home. The Licensee was advised that if any poisons are purchased, it is required to be locked with a key or combination lock.

Outdoor: LPA Rivera observed an AC unit compressor located in the backyard and informed licensee to place a safety gate or a barrier around the compressor in order to make it inaccessible to children as it poses a danger. LPA Rivera also observed a white bucket with plastic scraps. LPA Rivera advised to remove the bucket and place it in an area inaccessible to children as it poses a chocking hazard. Barbecue area is covered with a plastic cover. Right side gate, is used for emergency evacuation.

Per licensee, there are no pets, firearms, weapons or bodies of water on the premises. LPA Rivera observed age appropriate toys and napping equipment for the children. LPA Rivera observed 4 cribs with mattress and fitted sheets. Fire extinguisher located in the daycare room and the valve on the required 2A10BC fire extinguisher indicates fully charged (purchased May 19, 2020). Smoke and carbon monoxide detectors were tested by licensee and are operable. A fire alarm has been installed. First Aid kit is available; and located in a cabinet in daycare room.

The applicant has proof of pediatric First Aid/CPR certification (expires 03/2021). The applicant has proof of immunization against influenza, pertussis, and measles. The applicant completed the preventative health and safety training with lead component on 8/4/2020. The applicant was advised that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com.

LPA Rivera issued Forms/Records to Keep in Your Family Child Care Home (LIC 311D) to the applicant. LPA Rivera reviewed and provided material on the California Car Seat Law Changes (effective January 1, 2017), Effects of Lead Exposure, Shaken Baby Syndrome, Sudden Infant Death Syndrome (SIDS) and safe sleep practices.

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: KARIYAKARAWANA FAMILY CHILD CARE	FACILITY NUMBER: 198019361
	VISIT DATE: 08/11/2020

NARRATIVE

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Information to be posted in your home:
Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Notification of Parents’ Rights Poster (PUB 394), and Facility License (LIC 203).

Children’s Forms/Records to keep in your home:
Parent Notification, Additional Children in Care (LIC 9150), Affidavit Regarding Liability Insurance (LIC 282), Consent for Medical Treatment (LIC 627), Consent/Verification for Nebulizer Care (LIC 9166), Identification and Emergency Information (LIC 700), Notification of Parents’ Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), Family Child Care Consumer Awareness Information (LIC 9212), California School Immunization Record (blue card) (PM 286), and Acknowledgment of Receipt of Licensing Reports (LIC 9224), if applicable.

Facility Forms/Records to keep in your home:
1. Personnel Records as required in Title 22, Division 12, Chapter 3, Section 102416.1, including but not limited to, proof of current pediatric first aid, CPR, preventative health practices certificate, mandated reporter training certificate and criminal record information.
2. Unusual Incident/Injury Report (LIC 624B
3. Child Care Facility Roster (LIC 9040)
4. Notice of Employee Rights (LIC 9052)
5. Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108)
6. Property Owner/Landlord Consent Form (LIC 9149)
7. Property Owner/Landlord Notification Form (LIC 9151).
8. A copy of your deed or lease/rental agreement.

The following was also discussed with the applicant:
1. Individuals who are 18 years of age or older and living in the home must obtain a criminal record clearance. Individuals within one month of their 18^th birthday must be fingerprinted immediately. Failure to obtain 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.
2. In the absence of the licensee a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR and Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: KARIYAKARAWANA FAMILY CHILD CARE	FACILITY NUMBER: 198019361
	VISIT DATE: 08/11/2020

NARRATIVE

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3. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.
4. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be terminated
5. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
6. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
7. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B). Mandated reporter requirements were reviewed and explained.
8. Fire and safety drills must be performed every six (6) months and documented for review by the Department.
9. Smoking is prohibited in the family childcare home.
10. Children and staff records must be maintained and updated as needed and be available for review by the Department.
11. Dog(s) and/or pets are recommended to be isolated from children in care.
12. No baby bouncers, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into this category is not permitted in the facility.

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 Americans with Disabilities Act (ADA) was provided: U.S. 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 Rivera advised the applicant on how to access forms, regulations, quarterly updates, and Provider Information Notices (PIN) on the Department website: www.ccld.ca.gov.

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020

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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: KARIYAKARAWANA FAMILY CHILD CARE	FACILITY NUMBER: 198019361
	VISIT DATE: 08/11/2020

NARRATIVE

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As this time, the licensee is in compliance with California Title 22 Regulations. LPA Rivera will recommend the increase in capacity (14) as the licensee meets requirements for an increase and the fire clearance was received and granted for 14 children.

A final review of the application will be completed prior to licensure. Once licensed, the licensee is required adhere to the terms and limitations stated on the license.

Licensee stated a barrier will be put in place around the AC unit compressor on the weekend (August 15th or 16th, 2020), and will submit a picture.

Upon receipt the Licensee shall post the Notice of Site Visit. This report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty.

Exit interview was conducted with licensee Sangeetha Kariyakarawana, via teleconference. This report along with a copy of California Car Seat Law, Effects of Lead Exposure, Shaken Baby Syndrome, Sudden Infant Death Syndrome (SIDS), Safe Sleep Practices, Notice of Site Visit and the Appeal Rights will be sent to the Licensee via email with a read receipt to confirm receipt of the report.

SUPERVISOR'S NAME: Karen Chambers	TELEPHONE: (323) 981-3368
LICENSING EVALUATOR NAME: Mayra Rivera	TELEPHONE: (323) 629-7782
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020

LIC809 (FAS) - (06/04)

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