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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618260
Report Date: 01/21/2020
Date Signed: 01/21/2020 01:23:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:BALASURIYA, MIGNONFACILITY NUMBER:
343618260
ADMINISTRATOR:BALASURIYA, MIGNONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 363-2829
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY:14CENSUS: 12DATE:
01/21/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Mignon BalasuriyaTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Elvira Sierra met with the licensee, Mignon Balasuriya for the purpose of an unannounced annual random inspection. The licensee's husband was also present during the inspection. All individuals subject to criminal background review have obtained a criminal record clearance. Present in the facility were 12 preschool children being supervised by Licensee and 2 assistants. Facility hours of operation are M-F from 07:30 AM to 05:30 PM. Licensee stated there are no new residents in the home.

A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include; Bedroom # 3 (Storage Room), Bedroom #4 (Computer Room), Bathroom # 2 (inside master bedroom), Bathroom # 3, Kitchen (used to transition to napping area only). LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. There are no bodies of water on the premises. Toxic and hazardous items are inaccessible to children. Safety latches are in use on some kitchen cabinets and bathroom cabinets and drawers. The applicant understands that she must ensure the safety latches are not broken. Facility don't provide meals.

A random sample of children’s files were reviewed. Emergency information and required immunization records were on file. LPA observed a current roster and fire drills are conducted at least once every six months. The licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Updated Pediatric First Aid/ CPR was verified and expires on 04/21.

This provider is currently not providing IMS services to children in care. 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.

Report continues on 809-C.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2020
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: BALASURIYA, MIGNON
FACILITY NUMBER: 343618260
VISIT DATE: 01/21/2020
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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.

LPA verified the annual fees are current. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the licensee can request to be added to the distribution list to receive Quarterly Updates. LPA provided and discussed the Safe Sleep in Child Care and Effects of Lead Exposure brochures. Licensee stated she does not care for infants.

This facility evaluation report was reviewed and discussed with the licensee. A Notice of Site Visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.



This report was reviewed and discussed with Licensee. LPA conducted an exit interview. Based upon today’s inspection, No Title 22 deficiency were cited.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2020
LIC809 (FAS) - (06/04)
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