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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197403129
Report Date: 10/02/2024
Date Signed: 10/02/2024 02:40:31 PM

Document Has Been Signed on 10/02/2024 02:40 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:KALUWAHEWA FAMILY DAY CAREFACILITY NUMBER:
197403129
ADMINISTRATOR/
DIRECTOR:		KALUWAHEWA, SHIYAMAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 715-9909
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91303
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 2DATE:
10/02/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Shiyama KaluwahewaTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Tatiana Bickham conducted an unannounced annual required inspection at the above facility on 10/2/2024 at 12:18 PM. Upon arrival, LPA disclosed the purpose of the inspection and met with Shiyama Kaluwahewa License, who guided LPA on a tour of the facility. Entrance Checklist – Family Child Care Homes LIC 126 was provided to the Licensee to help facilitate the inspection. Also present was the Licensee’s spouse with assists with the day-care. There were (two) 2 day care children present during today’s inspection. Per Licensee, there are currently (six) 6 children enrolled. Facility capacity is in compliance for a large Family Child Care Home. Hours of operation are Mon-Sun 24 hours a day, per Licensee no children are here after 6:00 PM.

LPA toured the home inside and outside. This is a two story home which consists of 4 bedrooms, 3 bathrooms, kitchen, dining room, living room, den, enclosed patio, attached garage, front yard and backyard (fenced).



Per Licensee, areas off limits to children and parents include: The second floor which consist of 3 bedrooms and 2 bathrooms. The first floor which consist of 1 bedroom, dining room and kitchen. The front yard is off limits, and a portion of the backyard is off limits.

Per Licensee, areas that are accessible to children include: Living room, den, bathroom, enclosed patio and part of the backyard. The off-limits portion is separated by a gate. The bathroom that children use is located adjacent from the den and was observed to be clean and free of hazards.

Food is provided by Licensee. Licensee was reminded if children bring food from home, it must be labeled with the child’s name and properly stored or refrigerated.

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SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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 10/02/2024 02:40 PM - It Cannot Be Edited


Created By: Tatiana Bickham On 10/02/2024 at 01:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: KALUWAHEWA FAMILY DAY CARE
FACILITY NUMBER: 197403129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee will email LPA a copy of completed certificate by the date listed above. Training can be taken at mandatedreporterca.com
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 observation, interview, and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Licensee will email LPA a copy of immunization's by the date listed above.
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:Raul Navarro
LICENSING EVALUATOR NAME:Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KALUWAHEWA FAMILY DAY CARE
FACILITY NUMBER: 197403129
VISIT DATE: 10/02/2024
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All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection:

LPA reviewed required posted documentation for Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted in May 2024.

Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher indicated fully charged and was serviced within the year. The home maintains telephone service via landline and cell phone. The home is observed to be clean and orderly. There are toys and other age-appropriate materials available for children. Fireplace is screened to prevent access by children. Stairs have a gate to prevent access by children. LPA observed that detergents, cleaning compounds and medication are stored in under the sink in the off limits kitchen, inaccessible to children. Licensee states that there are no poisons stored in the home and understands that all poisons must be lock, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in the living room, away from the other children. Per Licensee there are no firearms or weapons stored in the home.

Infant Care: Currently licensee cares for 1 infants. LPA observed 1 play yards visible in the den. Napping equipment does not block entrances or exits. Infant mattresses were observed to be firm with tightly fitted sheets. LPA did not observe loose object, bumpers, objects hanging, or objects attached to the play yard. Per licensee wet or soiled sheets are removed and sent home to the parent to be washed. Each infant has their play yard and bedding. Bedding is returned to the parents weekly to be washed. LPA informed licensee of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, and provided PIN 20-24-CCP. Licensee states the following sleep supervision plan for infants: Licensee stays in the room while they nap.

Overnight Care: Per Licensee, no children enrolled stay over night. Licensee is aware that they must remain wake while children are awake. If children sleep in separate area from licensee, the door must remain open. If licensee cannot hear children when they wake up, video or audio device can be used.

Page 2.

SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
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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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KALUWAHEWA FAMILY DAY CARE
FACILITY NUMBER: 197403129
VISIT DATE: 10/02/2024
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Currently, children are using the back yard for outdoor play. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that could be hazardous to children in care. There are no pools or spas, or other bodies of water.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunizations Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, LIC 9227- Infant sleep form (0-12 months, and documentation of 15-minute Infant Sleep Check (0-24 months)

Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunizations against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate. At 1:00 PM LPA observed during file review the Licensee and assistant do not have a current Mandated Reporter Training Certificate, and do not have proof of immunizations against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment.


During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful, and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

Incidental Medical Services (IMS): 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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

Page 3.
SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KALUWAHEWA FAMILY DAY CARE
FACILITY NUMBER: 197403129
VISIT DATE: 10/02/2024
NARRATIVE
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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.

Licensee was reminded of their responsibility to report suspected child abuse. Mandatory Forms for the children’s files and provider’s files were discussed. Licensee was made aware that state law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category. Licensee was reminded that all infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome), and that the Provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome. LPA also informed licensee 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. Licensee was also reminded that only children eating may be in highchairs and that car seats are utilized only for transportation.



Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

The licensee was advised the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, (Type A violation), a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. The Licensee was made aware that they may file an appeal, in writing 15 business days from the date of receiving the penalty assessment.

During the exit interview, the LICENSEE, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Page 3.

SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KALUWAHEWA FAMILY DAY CARE
FACILITY NUMBER: 197403129
VISIT DATE: 10/02/2024
NARRATIVE
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Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Page 4.

SUPERVISORS NAME: Raul Navarro
LICENSING EVALUATOR NAME: Tatiana Bickham
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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