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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618260
Report Date: 05/16/2022
Date Signed: 05/16/2022 01:07:21 PM


Document Has Been Signed on 05/16/2022 01:07 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, 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: DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Mignon BalasuriyaTIME COMPLETED:
01:30 PM
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Li censing Program Analyst (LPA) Singh met with licensee, Gagandeep Singh, for an annual inspection. The purpose of the inspection was explained. Licensee lives in a single family home. During inspection, no children were present. Per licensee, licensee is not operating at this time. All adults living or working in the home have criminal background check on file.

LPA inspected the day care areas with the licensee. Day Care Areas: Classroom, Family room, Living room, Day care Roo #1, Day care room # 2 and Backyard. Off limit areas: Bedroom #3, Bedroom #4 and Kitchen. There is no pool, spa or any other body of water in the house. As per licensee, there is no firearm or weapon in the house. All the cleaning supplies, poisons and other chemicals are stored inaccessible to the children. Fireplace has metal screen protector in place. The house is in good repair and free of hazards with proper temperature and ventilation. There is carbon monoxide detector, smoke detector, fully charged fire extinguisher and working telephone available in the house. There is a variety of age appropriate toys in the house.

LPA reviewed the facility records. LPA observed licensee has License and other required documents posted in the child care areas. Licensee has record of training of preventive health and CPR card expired. Licensee stated that before licensee starts operating day care, licensee will obtain the new training. LPA remind the licensee to conduct the fire or emergency drills at least once every six months and drills must be logged. LPA reminded Licensee that all staff is required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. LPA discussed the safe sleep regulations and provided a copy of PIN 20-24-CCP.

See next page for continuation ..........
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep SinghTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: BALASURIYA, MIGNON
FACILITY NUMBER: 343618260
VISIT DATE: 05/16/2022
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LPA reminded the licensee that all adults, 18 years and older living in the home, helper or assistant must have criminal record clearance and must be associated to the facility prior to having any contact with children in care. Failure to do so could result in an immediate civil penalty of $100.00 each day.

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

LPA encourage the licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.



No deficiencies are cited today. The copy of this report is reviewed and provided to the licensee. Notice of site visit is posted and shall remain posted for next 30 days
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep SinghTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC809 (FAS) - (06/04)
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