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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313549
Report Date: 02/22/2023
Date Signed: 02/22/2023 12:51:46 PM


Document Has Been Signed on 02/22/2023 12:51 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: 3DATE:
02/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Licensee, Rasika FernandoTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dianna Valdez Santana conducted a case management visit related to a complaint received by the Orange Regional Office on 2/15/23.

LPA and licensee, Rasika Fernando toured the facility inside and outside and a census was taken as follow: 2 preschool age children and 1 infant in care. Present at the time was 2 staff including the licensee. A review of staff criminal clearance 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.

During today's inspection LPA Valdez Santana reviewed children and staff files. LPA observed that both the licensee and her assistant had expired Mandated Reporter training.

Based on LPA's inspection of the facility files, the following violation was observed is being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 1596.8662(b)(1), is being cited on the attached LIC 9099D.

Exit interview was conducted with licensee, Rasika Fernando. The Notice of Site Visit was posted. Facility representative was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. The Licensee was provided a copy of their appeal rights (LIC 9058 01/16) 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.

SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
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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Document Has Been Signed on 02/22/2023 12:51 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: FERNANDO, RASIKA
FACILITY NUMBER: 304313549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2023
Section Cited

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(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two
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Licensee agreed to submit mandated reporter certification to LPA by POC due date via email or mail.

www.mandatedreporterca.com
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 years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Based on [(observation) (record review)], the licensee did not comply with the section cited above. Licenseeand staff did not have a current mandated reporter certification available for review which poses/posed a potential health, safety or personal rights risk to persons 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: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
LIC809 (FAS) - (06/04)
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