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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334817748
Report Date: 10/13/2022
Date Signed: 10/14/2022 09:14:53 AM


Document Has Been Signed on 10/14/2022 09:14 AM - 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:PERERA FAMILY CHILD CAREFACILITY NUMBER:
334817748
ADMINISTRATOR:PERERA, SRIYANIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 371-8425
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY:14CENSUS: 5DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Sriyani Perera, LicenseeTIME COMPLETED:
04:45 PM
NARRATIVE
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On date and time listed, Licensing Program Analyst (LPA) Elyse Jones arrived at the facility to conduct a required/annual inspection as part of a compliance review. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:
Normal days and hours of operation are: Monday-Saturday 6:00AM-6:00PM
OFF-LIMIT AREAS INCLUDE: All of upstairs, Front Living Room, Front Dining Room, Laundry Room, Front Restroom, Front
The facility is operating within the licensed capacity and appropriate ratios
· Appropriate supervision provided during this inspection
· A working telephone is present and current number on file
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.
· Fireplace is properly screened to prevent access by children
· All hazardous items are stored inaccessible to children
· Toxins are locked
· Weapons are stored according to Title 22. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· Stairs are barricaded
· Verification of control of property on file
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Mandated Reporter Training completed on 8-8-2021
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PERERA FAMILY CHILD CARE
FACILITY NUMBER: 334817748
VISIT DATE: 10/13/2022
NARRATIVE
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· Pediatric CPR and First Aid Card expire on 7-2024
· Health & Safety Certificate - completed on 10-16-2012
· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Clean, safe and age appropriate toys
· Current roster on file
· Documentation of fire and disaster drills on file – Last drill conducted on 9-6-2022
· Children’s records are complete
· Employee records are complete
· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
· Resident and/or staff records reviewed on 10-13-2022 indicate that all adults who require caregiver background checks have NOT received all required clearances or exemptions. Two adult residents living in the home as of 10-7-2022. One of the adults is an Assistant.
· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov
- LPA discussed the safe sleep regulations with Sriyani Perera, Licensee 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 Sriyani Perera, 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.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PERERA FAMILY CHILD CARE
FACILITY NUMBER: 334817748
VISIT DATE: 10/13/2022
NARRATIVE
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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

- Sriyani Perera, 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.

- Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.



- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

See LIC809-D for cited deficiencies.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PERERA FAMILY CHILD CARE
FACILITY NUMBER: 334817748
VISIT DATE: 10/13/2022
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If a Civil Penalty has been assessed during this inspection. Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH.

The Sriyani Perera, Licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.



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.

Exit interview conducted and report was reviewed with the Sriyani Perera, Licensee.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/14/2022 09:14 AM - 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: PERERA FAMILY CHILD CARE
FACILITY NUMBER: 334817748

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
102370(d)(1)
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the interview and record review, the Licensee did not meet the above regulation which poses an immediate Health, Safety & Personal Rights risk to the children in care. During the interview the Licensee stated two adults residents moved in on 10-7-2022 until they decided on a place to live. One adult (S1) is the Licensee’s Assistant.
POC Due Date: 10/14/2022
Plan of Correction
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Licensee agrees to submit all required documentation for adult residents to obtain clearance by close of business on POC due date. Licensee understands prior to working, residing or volunteering all adults must obtain a criminal record clearance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 10/14/2022 09:14 AM - 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: PERERA FAMILY CHILD CARE
FACILITY NUMBER: 334817748

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
(j)The provider shall supervise infants while they are sleeping and adhere to the following requirements: (2)The provider shall check and document the following: (D) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: a. Date. b. Infant’s name. c. Time of each 15-minute check.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the interview and record review, the Licensee did not meet the above regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. During the interview the Licensee stated she thought sleep logs were supposed to be for infants up to 12 months.
POC Due Date: 10/17/2022
Plan of Correction
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Licensee agrees to submit sleep logs for C1 and C3 on or by POC due date. Licensee understands that all infants up to age 24 months require a sleep log to be on file.
Type B
Section Cited
HSC
1597.622(a)(1)
Staff/volunteer immunizations H&S 1597.622 (a)(1)
SB792 - 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.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses a potential Health, Safety & Personal Rights risk to the children in care. During the record review LPA was unable to review an immunization record for S1 showing proof of DTap vaccination. Licensee stated she will have S1 get the vaccination.
POC Due Date: 10/30/2022
Plan of Correction
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Licensee agrees to submit proof of vaccination for S1 on or by POC due date.
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: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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