197495097-5-27-2022-30-CC-LJCS-CETS43-20220527133205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197495097
Report Date: 05/27/2022
Date Signed: 05/27/2022 03:55:48 PM

Document Has Been Signed on 05/27/2022 03:55 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	SIRIWARDANA FAMILY CHILD CARE		FACILITY NUMBER:	197495097
ADMINISTRATOR:	IMESHA SIRIWARDANA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 715-6846
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	05/27/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Imesha Siriwardana		TIME COMPLETED:	12:00 PM

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On 5/27/2022, Licensing Program Analyst (LPA) Lillian Casillas conducted an announced Pre-Licensing Inspection for a family child care home. LPA met with Applicant, Imesha Siriwardana, who guided LPA on a tour of the inside and outside of the home. Applicant is the licensee of Beverly Hills Children's Academy #197419958. LPA observed 0 children in care. Hours of operation are scheduled for Monday through Friday, 7:00AM to 6:00PM.

Applicant is applying for a Large Family Child Care Home with maximum capacity of 14 children, ages 3 months to 6 years old. Fire safety clearance was received on 4/12/2022. Applicant is the owner of the home and provided LPA proof of ownership.

This is a single-story home with 3 bedrooms, 1 bathroom, living room, kitchen, detached laundry room, detached garage, front yard, and backyard. Childcare areas are: living room, bedroom 1, bedroom 2, bathroom, and backyard. Off-limits areas are: bedroom 3, detached laundry room, detached garage, and front yard.

Indoor

LPA entered the home through the front door that leads into the living room, which Applicant stated will be the primary child care area. In the living room, LPA observed 2 chairs, a children's floor mat, 1 TV secured the wall, 1 sofa, and the first-aid kit on a corner shelving unit. Bedroom 1, bedroom 2, and bathroom can be accessed via the hallway. In bedroom 1, LPA observed a children's table with 4 chairs, age-appropriate toys, children's floor mat, and books. In bedroom 2, LPA observed children's floor mat, 1 changing table, 1 pack n play, 2 high chairs, age-appropriate toys, and cubbies. In bathroom 1, LPA observed 1 toilet, 1 sink, and 1 shower/bath tub. LPA observed toilet paper stored in the cabinet underneath the sink. The shower is free of shampoos/conditioners.In the hallway, LPA observed a parent board on the wall with Emergency Disaster Plan, Notification of Family Child Care (PUB394), and a space for the License.

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SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Lillian J Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: SIRIWARDANA FAMILY CHILD CARE	FACILITY NUMBER: 197495097
	VISIT DATE: 05/27/2022

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Indoor Off-Limits
LPA observed a child safety lock on the door of bedroom 3. LPA observed child safety gates blocking off the kitchen from the hallway and living room.

Outdoor
LPA observed a large backyard with a shaded patio area and a shaded astro turf. The childcare area is enclosed with by metal gates on two sides and a brick wall. Additionally, the backyard is made inaccessible by two tall side gates. In the astro-turf area, LPA observed a children's house, slide, and water table.

Outdoor Off-Limits
Applicant stated the detached garage, detached laundry room, and front yard are off-limits. LPA observed a padlock on the detached garage door and a key lock on the door to the laundry room.

The 2A10:BC fire extinguisher is mounted to the wall in the kitchen. LPA observed functioning smoke/carbon monoxide detectors in the hallway and bedroom 1. LPA observed a functioning smoke detector in bedroom 2. Applicant states there are no firearms or weapons of any kind in the facility at the time of the visit. LPA observed all electrical outlets covered in on-limits areas of the home.

LPA discussed Child Care Resource Center, the local Resource & Referral agency, with Applicant to inquire about food programs, child care referrals, and professional development training. Connections for Children contact information: (818) 717-1000 ext. 4714, https://www.ccrcca.org/

Applicant understand that she must be present in the home and when circumstances require licensees to be temporarily absent from the home, licensees shall arrange for a substitute adult to care for and supervise children during her absence. Temporary absences cannot exceed 20 percent of the hours that the facility provides care per day.

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SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Lillian J Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: SIRIWARDANA FAMILY CHILD CARE	FACILITY NUMBER: 197495097
	VISIT DATE: 05/27/2022

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Criminal Record Statement
Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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

Safe Sleep

LPA discussed the safe sleep regulations with Applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Applicant 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.

Exit Interview
Exit interview conducted and report was reviewed with Applicant, Imesha Siriwardana.

Family Child Care Homes
LPA reviewed with Applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the Applicant.

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SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Lillian J Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: SIRIWARDANA FAMILY CHILD CARE	FACILITY NUMBER: 197495097
	VISIT DATE: 05/27/2022

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Subscribe to CCLD important information
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

LPA advised Applicant to call (424) 301-3077 and speak with the Office On Duty for any questions about regulations until she is assigned a LPA.

SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Lillian J Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC809 (FAS) - (06/04)

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