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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334840727
Report Date: 11/15/2021
Date Signed: 11/15/2021 12:07:22 PM

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 STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:JAYASINGHE FAMILY CHILD CAREFACILITY NUMBER:
334840727
ADMINISTRATOR:JAYASINGHE, RANJANIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 746-3256
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY:14CENSUS: 3DATE:
11/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Licensee Ranjani JayasingheTIME COMPLETED:
12:15 PM
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On the above date and time listed, Licensing Program Analyst (LPA) Susan Brewer, arrived unannounced at the facility for the purpose of conducting a case management visit. The LPA conducted a COVID-19 screening of the facility, was greeted by the Licensee Ranjani Jayasinghe and granted entry into the facility. LPA stated the purpose of the visit, toured the facility took a census.

The purpose of the visit was a follow-up to deliver a Technical Violation identified during a inspection conducted on 07/01/2021. During the inspection on 07/01/2021 the LPA S.Brewer, conducted a record review that was incomplete for a infant child in care, where required the enrollment packet was incomplete and safe sleep standard forms were missing. The Licensee Ranjani Jayasinghe, stated that the child was just re-enrolled that day and it was the child's first day back in care from a few months prior, however the Licensee was unable to provided proof records from the previous enrollment, when requested by the LPA.


No Civil Penalty has been assessed on 11/15/2021.

A NOTICE OF SITE VISIT WAS ISSUED AND LPA VERIFIED THAT IT WAS POSTED IN A PROMINENT LOCATION AT THE FACILITY BEFORE LEAVING. THE LICENSEE UNDERSTANDS THAT IT MUST REMAIN POSTED FOR THE NEXT 30 DAYS

A copy of this report was reviewed and provided to the Licensee Ranjani Jayasinghe and licensee's spouse Manjula Epa on 11/15/2021, and signed by Licensee spouse Manjula Epa.
SUPERVISOR'S NAME: Pauline BeschornerTELEPHONE: (951) 782-6641
LICENSING EVALUATOR NAME: Susan BrewerTELEPHONE: (951) 970-0343
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
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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