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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618260
Report Date: 01/06/2023
Date Signed: 01/06/2023 03:25:58 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/06/2023 03:25 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: 0DATE:
01/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mignon BalasuriyaTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Gagandeep Singh met with the licensee, Mignon Balasuriya, for an annual inspection. Purpose of the inspection was explained. There are no children present during today's inspection.

During inspection, the licensee informed the LPA that licensee is not operating at this time and does not plan to operate in near future. LPA informed the licensee that licensee can either close her license or be placed on inactive status. Licensee decided to be on Inactive status. During today's inspection, LPA collected the Inactive status request form from the licensee. As of today, the license will be placed on inactive status. LPA informed the licensee that licensing fee must remain current.

No deficiencies were cited today. Copy of this report was reviewed and provided to the licensee. Notice of site visit was provided.
SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep SinghTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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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