198019361-8-4-2022-54-CC-JESA-CGYRYL-20220804132632

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198019361
Report Date: 08/04/2022
Date Signed: 08/04/2022 01:26:55 PM

Document Has Been Signed on 08/04/2022 01:26 PM - 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:	KARIYAKARAWANA FAMILY CHILD CARE		FACILITY NUMBER:	198019361
ADMINISTRATOR:	SANGEETHA KARIYAKARAWANA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(310) 256-9910
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	14	CENSUS: 6	DATE:	08/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Licensee Sangeetha Kariyakarawana		TIME COMPLETED:	01:40 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	On 8/4/22 Licensing Program Analysts (LPAs) Jeanette Estrada and Austin Estrada conducted an unannounced required 1 year inspection at the above facility. LPAs met with the Licensee Sangeetha Kariyakarawana and informed her of the purpose for the visit. LPAs provided Licensee with a copy of the Facility Entrance Checklist. Licensee guided LPAs on a tour of the facility. There were 6 children present during the inspection. At 9:20 AM LPAs observed 4 infants and 2 toddlers present in the home. An Assistant provider was not present. All residents were noted and verified. Facility provides care to children ages 0 to 6 years old . Facility is open Monday to Friday 6:30 AM to 6PM. At 10:47 AM child 1 was picked up from the facility leaving the facility in compliance with capacity requirements for a small license since an assistant provider was not present. This is a two story home with 4 bedrooms, 3 bathrooms, living room, dining room, kitchen, attached garage and backyard . Areas on limits to children are: 1 bedroom downstairs used as the day care room, dining room, bathroom downstairs and backyard. Areas off limits to children are: all bedrooms upstairs, bathrooms upstairs, living room, kitchen and garage. Licensee was advised to submit an updated facility sketch which indicates off limit areas. All areas that are accessible to children were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection: LPA reviewed required posted documentation for Facility License with Licensee. LPAs observed the required documents to be posted: Facility license, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. The following facility records were observed during the inspection: LIC 610- Facility Disaster Plan and Disaster drill log. Last documented drill date: 6/20/2022. There was a current roster LIC 9040 available in the facility. There is an operable carbon monoxide detector/ smoke detector in the facility. LPA J. Estrada observed a 2A10BC Fire Extinguisher in the day care room that was last serviced in June 2021. The home maintains telephone service (cell phone). Children bring food from home.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette Estrada	TELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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: KARIYAKARAWANA FAMILY CHILD CARE	FACILITY NUMBER: 198019361
	VISIT DATE: 08/04/2022

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Licensee was reminded if children bring food from home it must be labeled with the child’s name and properly stored or refrigerated. LPAs observed children's lunch bags. The home is observed to be clean and orderly. There are toys and other age appropriate materials available for children.
Sharp objects, detergents and cleaning compounds were observed in the kitchen, not inaccessible to children. Per Licensee, the kitchen is off limits but the dining room is on limits. Per Licensee, the dining room is currently not used by day care children. Licensee was reminded that hazardous items are required to be inaccessible to children at all times. LPA observed cleaning products in an unlatched cabinet under the kitchen sink and Knives were on the kitchen counter on a knife block. There is no safety gate preventing access to the kitchen from the dining room. During the inspection, Licensee installed a latch on the cabinet and removed the knives from the counter and placed them in the garage.
Per Licensee no children enrolled require medication. Personal medication is kept in an off limits bedroom upstairs. LPAs observed a safety gate at the bottom of the stairs. The home has central AC and heating LPA did not observe any fireplaces in the home. Children use the downstairs restroom next to the day care room and are supervised.
Children use the backyard for outdoor play.
Per Licensee, there are no poisons in the home. Licensee understands that all poisons must be locked, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in the day care room separated from other children. Per Licensee, there are no firearms or weapons stored in the home. LPA did not observe pools or spas, or other bodies of water. Per Licensee, there are no pets in the home.
Infant Care: Currently Licensee has 4 infants enrolled. LPAs observed 4 infants in cribs and play yards in the day care room. LPA observed blankets, stuffed animals in the cribs/ play yards and two infants had an activity gym with a blanket attached in their crib/play yard. Licensee removed the items from the cribs during the inspection. Licensee was advised that napping equipment should not block entrances or exits. Infant mattresses should be firm with tightly fitted sheets. LPA discussed that each infant enrolled must have their own crib/ napping mat and bedding. LPA discussed with licensee of the Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, will provide PIN 20-24-CCP to Licensee. Overnight Care: There is no overnight care provided at the moment. LPA discussed the following: Licensee is aware that they must remain wake while children are awake. If children sleep in separate area from licensee, the door must remain open. If licensee cannot hear children when they wake up, video or audio device can be used.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette Estrada	TELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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: KARIYAKARAWANA FAMILY CHILD CARE	FACILITY NUMBER: 198019361
	VISIT DATE: 08/04/2022

NARRATIVE

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Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization Records, LIC 700- Identification and Emergency Information, , LIC 995A Notification of Parents’ Rights. 6 out of 6 children were missing LIC 627- Consent for Medical Treatment and 4 out of 6 children were missing the infant sleep log.
Licensee's Pediatric CPR/First Aid was completed on 4/1/2021. Mandated Reporter training was completed on 12/10/2020. Licensee was reminded that Mandated Reporter training is required to be completed every 2 years. Per Licensee, currently there is no Assistant employed.
During inspection the children present was observed to be treated with dignity and respect, furnishings and equipment, and free from corporal and/or unusual punishment. Issues with safe and comfortable accommodations were cited on LIC 809-D.
Incidental Medical Services (IMS): 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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm Licensee was reminded that all adults 18 and over living or working in the home, 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. 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.
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/process.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette Estrada	TELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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: KARIYAKARAWANA FAMILY CHILD CARE	FACILITY NUMBER: 198019361
	VISIT DATE: 08/04/2022

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The deficiencies listed on the following pages were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Two type A citations were issued today for CCR 102425(b) Infant Safe Sleep and CCR 102416.6(b)(2) Staffing Ratio and Capacity. Please see attached LIC 809-D for all citations.
Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

The notice of site visit was posted where the parent/guardian of children enter and exit the facility.
A copy of this report shall also be posted where the parent/guardian of children enter and exit the facility.
Both the notice of site visit and licensing report shall remain posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty.
A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon their return.
A copy of this report shall also be provided to the parent/guardian of any newly enrolled child for the next 12 months.
A signed Acknowledgement of Receipt (LIC9224) shall be in each child’s file, acknowledging receipt.

Exit interview conducted and report was reviewed with the Licensee, Sangeetha Kariyakarawana. A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3828
LICENSING EVALUATOR NAME: Jeanette Estrada	TELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/04/2022 01:26 PM - 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: KARIYAKARAWANA FAMILY CHILD CARE	FACILITY NUMBER: 198019361
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102425(b)

Infant Safe Sleep

(b) Cribs or play yards shall be free from all loose articles and objects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs observed infants in cribs and play yards with items inside which included blankets and stuffed toys and 2 infants had an activity gym inside their crib/ play yard which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2022
	Plan of Correction
1 2 3 4	Licensee removed the items from the cribs.

Type A

Section Cited

CCR

102416.5(b)(2)

Staffing Ratio and Capacity

(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: (2) Six children, no more than three of whom may be infants; or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. There were 4 infants and 2 toddlers present when LPAs arrived. There was no Assistant provider with the Licensee which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2022
	Plan of Correction
1 2 3 4	Licensee had child 1 picked up at 10:47 AM. Licensee will submit an attendance schedule for the infants that will prevent the facility from being out of ratio when there is no assistant provider.

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) 513-3828
LICENSING EVALUATOR NAME: Jeanette Estrada	TELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/04/2022 01:26 PM - 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: KARIYAKARAWANA FAMILY CHILD CARE	FACILITY NUMBER: 198019361
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(1)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. The Fire Extinguisher in the day care room was last serviced in June 2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2022
	Plan of Correction
1 2 3 4	Licensee will have fire extinguisher serviced or purchase a new one and will submit a picture to LPA by the due date

Type B

Section Cited

CCR

102417(g)(4)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed cleaning compounds in an unlatched kitchen cabinet under the sink and knives on the counter which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2022
	Plan of Correction
1 2 3 4	Licensee installed a latch on the cabinet with the cleaning products and removed the knives from the counter and placed them in the garage.

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) 513-3828
LICENSING EVALUATOR NAME: Jeanette Estrada	TELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/04/2022 01:26 PM - 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: KARIYAKARAWANA FAMILY CHILD CARE	FACILITY NUMBER: 198019361
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2022

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 interview and record review, the licensee did not comply with the section cited above in 4 out of 4 infant's records which did not contain an infant sleep log which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2022
	Plan of Correction
1 2 3 4	Licensee will review Infant Safe Sleep regulation 102425 and will document 15 minute sleep checks. Licensee will submit proof to LPA via picture by due date.

Type B

Section Cited

CCR

102416.5(e)

Staffing Ratio and Capacity

(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. No assistant provider was present during the inspection and there were 6 children present (4 infants and 2 toddlers) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2022
	Plan of Correction
1 2 3 4	Licensee had child 1 picked up at 10:47 AM leaving the facility in compliance with the capacity requirements for a small family child care home. Licensee will submit a declaration that facility will comply with small family child care home capacity requirements until a qualified assistant provider is hired.

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) 513-3828
LICENSING EVALUATOR NAME: Jeanette Estrada	TELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/04/2022 01:26 PM - 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: KARIYAKARAWANA FAMILY CHILD CARE	FACILITY NUMBER: 198019361
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(7)

(g) The home shall be free from defects or conditions which might endanger A child. Safety precautions shall include but are not limited to (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 reviw, the licensee did not comply with the section cited above in 6 out of 6 children's records which did not contain LIC 627 Consent for emergency medical treatment which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2022
	Plan of Correction
1 2 3 4	Licensee will provide LIC 627 to parents/ authorized representatives to sign. Licensee will submit proof to LPA via picture.

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) 513-3828
LICENSING EVALUATOR NAME: Jeanette Estrada	TELEPHONE: (323) 229-6521
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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