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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313549
Report Date: 04/20/2022
Date Signed: 04/20/2022 04:08:27 PM


Document Has Been Signed on 04/20/2022 04:08 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:FERNANDO, RASIKAFACILITY NUMBER:
304313549
ADMINISTRATOR:FERNANDO, RASIKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 853-8420
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:14CENSUS: 9DATE:
04/20/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Rasika Fernando - LicenseeTIME COMPLETED:
04:20 PM
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A case management plan of correction inspection was conducted by LPA Carmen Odom. LPA met with the licensee Rasika Fernando. This inspection is being conducted in response to one Type A violation cited on 4/12/22 during an annual inspection. On 4/12/22 the facility had 12 children in care, 5 of which were infants. An assistant was present providing care along with the licensee. The facility was cited a Type A violation for over-capacity, in a large family childcare home license there cannot be more than 4 infants in care. In response to the violation the licensee called parent to pick up infant #5 immediately on the day of the visit, and licensee stated they will not operate over capacity, no more than 4 infants at one time. During today's Plan of Correction inspection, it was observed that 9 children were in care, 3 of whom were infants, 4 preschool age children and 2 school age children. During today's Plan of Correction inspection, it was observed that the facility was within compliance of capacity regulations. A ratio pamphlet, safe sleep concepts, and Guide to Safe Sleep was provided to the licensee and were discussed.

Exit interview was conducted, and report was reviewed and discussed with Licensee. Notice of Site Visit was posted during the visit. The licensee and licensee's spouse were informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100 per day. The assistants were provided a copy of the appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional manager, address is above on the report.

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
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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