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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845781
Report Date: 02/15/2022
Date Signed: 02/15/2022 02:59:09 PM


Document Has Been Signed on 02/15/2022 02:59 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501



FACILITY NAME:KUMARAPPERUMA FAMILY CHILD CAREFACILITY NUMBER:
334845781
ADMINISTRATOR:KUMARAPPERUMA,MARIAN SHERMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 207-2848
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:14CENSUS: 7DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Marian KumarapperumaTIME COMPLETED:
03:04 PM
NARRATIVE
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On date and time listed, Licensing Program Analysts (LPAs) Kay Phillips and Elyse Jones arrived at the facility to conduct an annual inspection. LPAs toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:
Normal days and hours of operation are: Mondays to Fridays 6am to 6pm.
OFF-LIMIT AREAS INCLUDE: all of upstairs, the den downstairs and the garage.
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
· 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 08/22/2021
· Pediatric CPR and First Aid Card expires on 12/2023
· Health & Safety Certificate on file
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Karrene PhillipsTELEPHONE: 951-970-1161
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
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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Document Has Been Signed on 02/15/2022 02:59 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: KUMARAPPERUMA FAMILY CHILD CARE
FACILITY NUMBER: 334845781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review/interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. During the inspection Licensee stated C7 started on 2-14-2022 and she does not have a sleep log available for review.
POC Due Date: 02/18/2022
Plan of Correction
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Licensee started sleep log during inspection for C7. Licensee agrees to submit additional copies of sleep log to the Department on 2-18-2022. Licensee understands that all infants require a sleep log.
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review/interview the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. During record review the LPA was unable to review an LIC 501, LIC 503,
LIC 508 and an LIC 9052.
POC Due Date: 02/18/2022
Plan of Correction
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Licensee agrees to submit all required documents to the Department 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) 248-0228
LICENSING EVALUATOR NAME: Karrene PhillipsTELEPHONE: 951-970-1161
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/15/2022 02:59 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: KUMARAPPERUMA FAMILY CHILD CARE
FACILITY NUMBER: 334845781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review/interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. During record review LPA reviewed an imcomplete immunization record for S1.
POC Due Date: 03/01/2022
Plan of Correction
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Licensee agrees to submit a complete immunization record for S1 to the Department on or by POC due date. Licensee understands that all staff require TDap, MMR, TB and a yearly Flu vaccine or declination.
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. During inspection Licensee stated she does not have a file for C7 available for review during inspection.
POC Due Date: 02/18/2022
Plan of Correction
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Licensee agrees to submit all required documents for C7 to the Department on or by POC due date. Licensee understands all children in care must have a file with required documents.

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) 248-0228
LICENSING EVALUATOR NAME: Karrene PhillipsTELEPHONE: 951-970-1161
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/15/2022 02:59 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501


FACILITY NAME: KUMARAPPERUMA FAMILY CHILD CARE
FACILITY NUMBER: 334845781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review/interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. During record review LPA observed C3 and C7 missing from the facility roster. Licensee understands that all chidlren enrolled must be listed on the facility roster.
POC Due Date: 02/15/2022
Plan of Correction
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Licensee corrected during inspection
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) 248-0228
LICENSING EVALUATOR NAME: Karrene PhillipsTELEPHONE: 951-970-1161
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
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: KUMARAPPERUMA FAMILY CHILD CARE
FACILITY NUMBER: 334845781
VISIT DATE: 02/15/2022
NARRATIVE
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· 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 not on file
· Documentation of fire and disaster drills on file – Last drill conducted on 01/11/2022
· Children’s records are not complete
· Employee’s records are not 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 02/14/2022 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.
· 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 licensee and 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 licensee Marian Kumarapperuma 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.
- This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Karrene PhillipsTELEPHONE: 951-970-1161
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
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: KUMARAPPERUMA FAMILY CHILD CARE
FACILITY NUMBER: 334845781
VISIT DATE: 02/15/2022
NARRATIVE
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Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
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
- 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.

A notice of site visit was given and must remain posted for 30 days
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Also, LPA Kay Phillips informed the licensee to provide a copy of this licensing report dated 02/14/2022.

The LICENSEE, Marian Kumarapperuma, confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

Exit interview conducted and report was reviewed with the licensee, Marian Kumarapperuma.
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Karrene PhillipsTELEPHONE: 951-970-1161
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
LIC809 (FAS) - (06/04)
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