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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312736
Report Date: 05/07/2019
Date Signed: 05/07/2019 04:19:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MEDAGANGODA, ROHITHAFACILITY NUMBER:
304312736
ADMINISTRATOR:MEDAGANGODA, ROHITHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 318-5511
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:14CENSUS: 11DATE:
05/07/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Rohitha MedagangodaTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hawkins toured the facility inside and outside with the licensee. The home was clean, orderly, and was at a comfortable temperature for the children present. Upon arrival LPA contacted the licensee who was away from the home. Licensee arrived back to the home within 5 minutes of LPA's arrival. Census was taken, and there were eleven children (ages 2 to 5 years old) with the licensee and two assistants. The facility was within licensed capacity and the required ratio.

A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

LPA toured areas of the home accessible to the children. The home consists of one story home with 3 bedrooms and 3 bathrooms. Licensee stated that off limit areas include: all bedrooms, master bath and main bathroom in bedroom hallway, both sides yard (only using cement area), and garage.



There are no accessible bodies of water or firearms on the premises. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children were properly stored and or locked away. The smoke detector, fire extinguisher, and carbon monoxide detector were present and within regulations. The toys appear age appropriate and in good condition for the ages served. CPR & First Aid are current for licensee (exp. CPR/First-aid 3/2020 ). Posting requirements were met. Children files included emergency disaster forms.

Continued on page 2.

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2019
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MEDAGANGODA, ROHITHA
FACILITY NUMBER: 304312736
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2019
Section Cited
HSC
1596.841
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Current roster of children provided care in facility required. Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and
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The licensee plans to resolve the violation by submitting copy of the missing roster to the Licensing office by the due date via email or mail to LPA. LPA provided contact information.
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telephone number of the child's physician. This roster shall be available to the licensing agency upon request. This requirement was not met as evidenced by no roster present for review.This poses a potential safety risk to the children in care.
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Type B
05/31/2019
Section Cited
HSC
1597.622
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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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Licensee stated he will submit proper immunization information by the due date to the licensing office vial email or by mail.
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This requirement was not met as evidenced by Staff #2 did not have proof of immunization against pertussis and measles available for review during the inspection. This posses a potential Health and Safety risk to children in care.
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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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MEDAGANGODA, ROHITHA
FACILITY NUMBER: 304312736
VISIT DATE: 05/07/2019
NARRATIVE
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Page 2

The home uses a landline telephone for child care, but also has a cell phone that is used for child care. The licensee was reminded that the cell phone or a working phone must remain on the premises at all times during hours of operation.

The licensee was reminded that he must be present at facility to ensure that children are properly cared for and supervised at all times. The licensee must make sure that a substitute adult cares for the children when licensee is temporarily absent. The licensee was also reminded that no child shall be left alone in a parked vehicle at any time.

The licensee stated he will not provide 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 Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

A Child Care Provider’s Guide to Safe Sleep packet, Never Shake a Baby, and Safety Seat information were discussed and provided to the licensee. The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf. The licensee was also informed that he can get Licensing Updates at www.ccld.ca.gov

LPA reviewed Unusual Incident Report form-advised to contact Licensing Officer of the Day within 24 hours and complete the Unusual Incident Report (LIC 624B) within 7 days.LPA reminded licensee of requirements of disaster drills (documented every 6 months), posting requirements, children records, mandated child abuse and injury/death reporting.

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MEDAGANGODA, ROHITHA
FACILITY NUMBER: 304312736
VISIT DATE: 05/07/2019
NARRATIVE
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LPA observed no children's roster present in the home, and Staff #2 was missing required immunization of Pertusis (TDAP) and Measels (MMR). This poses a potential safety risk to the children in care.

The facility was not in compliance and violations of the California Code of Regulations, H&S code section 1597.622 , H&S code 1596.841 were observed, discussed and cited at the time of the visit. (See LIC 809-D for specific deficiencies)

Appeal Rights and deficiencies were discussed.

The licensee was provided a copy of appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the licensing office within 15 business days.

An exit interview conducted where the report was discussed with the licensee. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4