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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020804
Report Date: 06/17/2021
Date Signed: 06/17/2021 10:49:22 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:SUNNADENIYAGE FAMILY CHILD CAREFACILITY NUMBER:
198020804
ADMINISTRATOR:RUKSHANI SUNNADENIYAGEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 841-0857
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:14CENSUS: DATE:
06/17/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Applicant, Rukshani SunnadeniyageTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA), Bardo Baluyot conducted an announced pre-licensing inspection for the above facility. LPA met with Rukshani Sunnadeniyage, who guided Analyst on a tour of the facility. Family members residing in the home are two adults and two children. Ms. Wasalamudalige, applicant’s mother is currently licensed as a large family childcare (#198020285) but will surrender her license as soon as license is granted for Ms. Sunnadeniyage. Per applicant, she plans on operating Monday-Friday from 6:30 AM to PM.

All areas identified on the facility sketch were inspected. This is a single-story home which consists of 4 bedrooms, 2 restrooms, kitchen, living room (day care room), dining room, backyard (fenced). The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. LPA observed age appropriate toys and equipment on the premises.

Areas used by children include: Bedroom #1, living restroom (Day Care Room) and the restroom located in the hallway. There are pressure gates in place to prevent children from accessing off limit areas. Backyard is fenced and there are no bodies of water such as a swimming pool, spa or pond. Licensee's CPR/First Aid are valid until 10/2021. The required fire extinguisher (2A10BC) was serviced on 6/2/21. Smoke and carbon monoxide detectors were found in operable condition. Per licensee, there are no weapons, firearms in the facility at this time. First Aid kit is available in the home.

Infant Care: Infants will use bedroom #1 to nap in. Per applicant, she will keep the door open to ensure that infants can be supervised. LPA provided the applicant with a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. Mandated Reporter training was discussed. Training must be renewed every two years and can be found at: www.mandatedreporterca.com/training New immunization requirements were also discussed.

SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3351
LICENSING EVALUATOR NAME: Bardo BaluyotTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: SUNNADENIYAGE FAMILY CHILD CARE
FACILITY NUMBER: 198020804
VISIT DATE: 06/17/2021
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LPA REVIEWED FORMS TO BE POSTED and REQUIRED FORMS: Facility Records: LIC 624B (Unusual Incident/Injury Report), LIC 9040 (Child Care Facility Roster), LIC9052 (Employee Rights), LIC9108 (Statement Acknowledging Requirement to Report Child Abuse)

Staff Forms/Records - Any assistant present must have the following on file: Proof of TB clearance (within one year), Notice of Employee Rights (LIC 9052), Criminal Record Statement (LIC 508), Statement Acknowledging Requirements to Report Suspected Child Abuse (LIC 9180).

Children’s records requirements: (LIC 700) Identification and Emergency Information, (LIC 627) Consent For Emergency Medical Treatment, (LIC 282) Affidavit Regarding Liability Insurance, (LIC 9150) Parent Notification Additional Children In Care, Immunization records, (PUB 72) Family Child Care Consumer Guide, (LIC995A) Notification of Parent’s Rights

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



The applicant understands that once the license is granted for a large family childcare home she is required to adhere to the terms and limitation as stated on the license. Fire clearance has been granted. There are no pending corrections, facility will be licensed for a large family child care home. No deficiencies cited.
LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing Website at: www.ccld.ca.gov

Exit interview was conducted with applicant, who is in agreement with the above. Notice of Site Visit provided and must be posted. Appeal rights discussed.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3351
LICENSING EVALUATOR NAME: Bardo BaluyotTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: SUNNADENIYAGE FAMILY CHILD CARE
FACILITY NUMBER: 198020804
VISIT DATE: 06/17/2021
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The following was discussed with the licensee:
·Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearance prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.
·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 & Pediatric First Aid certification, TB clearance, and a valid criminal record clearance associated to the facility license.
·A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.
·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.
·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.
·Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Mandated reporter requirements was reviewed and explained.
·Fire and safety drills must be performed every six months and documented for review by the Department.
·Smoking is prohibited in a family child care home, 24/7.
·Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
·No smoking, No baby bouncers, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.
·All adults living and working in the home shall be made of aware of the Departments right to inspection authority.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3351
LICENSING EVALUATOR NAME: Bardo BaluyotTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC809 (FAS) - (06/04)
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