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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197492889
Report Date: 08/31/2022
Date Signed: 08/31/2022 02:31:28 PM


Document Has Been Signed on 08/31/2022 02:31 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:KANNANGARA FAMILY CHILD CAREFACILITY NUMBER:
197492889
ADMINISTRATOR:KANNANGARA,ATHUDARACHCHIGEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 217-9877
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:14CENSUS: 2DATE:
08/31/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Athudarachchige Dona Nathasha Kannangara, LicenseeTIME COMPLETED:
02:35 PM
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On 8/31/2022 Licensing Program Analyst (LPA) Shandra Powell conducted a Unannounced case management visit during a inspection.There were 2 Infant children present, licensee and one other adult.

During today's visit LPA observed both infants awoke standing up over the sides of their play yards, LPA observed large teddy bears and toys in each play yard with infants. LPA also notice the sheets on the bottom of the play yards were not the size sheet that fitted the play yard mattress used during inspection (photos taken). LPA also notice the play yards appeared to be dirty and needed cleaning and or bought new. Licensee agreed to buy new play yards during inspection. LPA also observed a roach crawling on dining room table during inspection while LPA wrote this report. Licensee states she does not have a infestation of roaches at her facility and will provide an invoice to LPA by Monday 09/06/2022 via email. LPA provided licensee with technical assistance; operation of family child home and safe sleep practices.

LPA discussed Infant safe sleep practices, licensee removed the soft toy from the Play yards and explained to LPA they do not nap with items. During the inspection LPA observed all items were taken out of the play yards. LPA provided licensee with PIN 20-24 CCP- new safe sleep regulation 102425. Licensee was directed to visit CCLD website to gather more information about safe sleep practices. LPA discussed Individual Sleeping Plan LIC 9227, LPA provided a copy to licensee.
SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Shandra PowellTELEPHONE: (424) 301-3053
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
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 08/31/2022 02:31 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: KANNANGARA FAMILY CHILD CARE
FACILITY NUMBER: 197492889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2022
Section Cited

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Infant Safe Sleep -Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress,
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and overlaps the underside of the mattress so it cannot be dislodged.The requirement is not met as evidenced by LPA observed loose sheets on each Play Yard during inspection.This poses a potential risk to the health and safety of children in care.
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POC 09/06/2022
Type B
09/06/2022
Section Cited

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(c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file.

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(1) This plan shall be signed and dated by the infant’s authorized representative.

(2) The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review ..This poses a potential risk to the health and safety of children in care..

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licensee will send photo of completed form by email to LPA.
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: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Shandra PowellTELEPHONE: (424) 301-3053
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: KANNANGARA FAMILY CHILD CARE
FACILITY NUMBER: 197492889
VISIT DATE: 08/31/2022
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During inspection a file review was conducted. LPA did not observe the LIC 9227 in infant files. LPA advised licensee to complete form for all infants up to 12 months of age. LPA provided licensee with PIN 19-02-CCP during inspection.
The following deficiencies listed on the attached LIC 809 (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.

LPA provided licensee with the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources. LPA guided licensee to site during inspection and observed licensee become a subscribed member.


Exit interview conducted. LPA reviewed this report. Notice of site Visit Given and must be posted for 30 days.
SUPERVISOR'S NAME: Karren StarksTELEPHONE: (424) 301-3069
LICENSING EVALUATOR NAME: Shandra PowellTELEPHONE: (424) 301-3053
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC809 (FAS) - (06/04)
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