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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495097
Report Date: 06/24/2026
Date Signed: 06/24/2026 01:22:35 PM

Document Has Been Signed on 06/24/2026 01:22 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:SIRIWARDANA FAMILY CHILD CAREFACILITY NUMBER:
197495097
ADMINISTRATOR/
DIRECTOR:		IMESHA SIRIWARDANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 715-6846
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
06/24/2026
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Apsara Kandaudage, AssistantTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 06/24/2026, Licensing Program Analyst (LPA) Elicia Calvillo conducted an unannounced Required 3-Year inspection at 1720 N. Ontario Street, Burbank, CA. 91505. LPA arrived at the facility at 08:20 AM, identified self and met with Apsara Kandaudage, Assistant, who guided analyst on a tour of the inside and outside of the facility. Assistant stated the Licensee was away from the facility at an appointment. There were three (3) children present upon arrival. LPA provided Assistant with a copy of the LIC126 Entrance Checklist to help facilitate the inspection. Facility operation hours are Monday to Friday from 8:00AM to 05:30PM.

The Licensee was not present at the facility from 08:25AM to 01:15PM. One Type B citation for California Code of Regulations section 102417(a) Operation of A Family Child Care Home was issued.

The family child care home is a one story dwelling with a living room, kitchen/dining room, bedroom #1, bedroom #2, bedroom #3, bathroom #1, and detached garage. There is an unfenced front yard and a fenced backyard.

The children enter the child care home facility from the front door.

During the tour, LPA observed that bedroom #1 is used for child activities, indoor play, learning lessons, and sleeping. LPA observed there were safe toys, play equipment, tables, chairs and other materials that were appropriate for the ages of the children. LPA observed that bedroom #2 is used for infant sleeping, storage of children’s personal items, and storage of cots. LPA observed there are cubbies with bins for each child to

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NAME OF LICENSING PROGRAM MANAGER: Rita Ramos
NAME OF LICENSING PROGRAM ANALYST: Elicia Calvillo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/24/2026 01:22 PM - It Cannot Be Edited


Created By: Elicia Calvillo On 06/24/2026 at 12:17 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: SIRIWARDANA FAMILY CHILD CARE
FACILITY NUMBER: 197495097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, , the licensee did not comply with the section cited above in that the Licensee was not present at the facility from 08:25 AM to 01:00PM which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2026
Plan of Correction
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Licensee was not present during the inspection, Licensee will provided documentaion of appointment to LPA by the plan of correction due date 07/01/2026.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 of 3 personal records did not contain a complete immunization record readily available to the Deparatment upon request which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2026
Plan of Correction
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Licensee was not present during the inpection. Assistant stated that they will provide LPA with immunization records by the plan of correction due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Rita Ramos
NAME OF LICENSING PROGRAM MANAGER:
Elicia Calvillo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/24/2026 01:22 PM - It Cannot Be Edited


Created By: Elicia Calvillo On 06/24/2026 at 12:17 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: SIRIWARDANA FAMILY CHILD CARE
FACILITY NUMBER: 197495097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that 4 out 5 children's records did not contain current immunization records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2026
Plan of Correction
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Licensee was not present at the facility. Assitant stated that they will updated the children's immuniazation records and provide LPA with a copy by the plan of correction due date 07/08/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Rita Ramos
NAME OF LICENSING PROGRAM MANAGER:
Elicia Calvillo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2026


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: SIRIWARDANA FAMILY CHILD CARE
FACILITY NUMBER: 197495097
VISIT DATE: 06/24/2026
NARRATIVE
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store their personal items and there is a changing table with shelves that store diapers. LPA observed there are cots and bedding is provided by the parents which is laundered weekly. LPA observed that the living room is used for eating and that there are tables, chairs, and high chairs, that are safe and appropriate for the ages of the children. LPA observed bathroom #1 located in the hallway near kitchen/dining room is accessible to children, the vanity cabinet holds paper products. The bathroom is safe and sanitary.

LPA observed that the kitchen is used as a walkway to the outdoor play yard. When the kitchen is not in use there are child proof gates at the entrance from the hallway and living room. LPA observed that the outdoor play area is located in the back yard was in a safe condition, free of sharp, loose, or pointed parts, in good repair, and play materials are age appropriate. The surface of the outdoor play area is cement, artificial grass, and maintained in a safe condition and free of hazards. There is adequate shade with the use of a canopy.

During the indoor tour, the door to bedroom #3 was open, LPA observed a bed, dresser, and toy were stored in the bedroom. Bedroom #3 door was open, per the facility sketch bedroom #3 is off limits to parents and children, Assistant stated that bedroom #3 is not used for day care, LPA advised that the door should be closed during the hours of operation. During the outdoor tour, LPA observed that there was no fence separating the facility from the property next door located at 1716 N. Ontario Street, Burbank, CA. 91505 and there was direct access to the facility from the gates (photograph taken) to the back yard and windows.

LPA reminded Licensees that children are to be supervised at all times. LPA advised Licensee that children shall not be left in parked vehicles and car seats are used for transportation purposes only and are not used for sleeping children.

Assistant stated that when a child shows signs of an illness the child will be isolated in the living room, away from the other children until their parents arrive.

There is a combination smoke and carbon monoxide detector located in the hallway near bedroom #1 and bedroom #2, which was tested and is operable. There is a working fire extinguisher, the valve on the required 2A:10BC fire extinguisher indicates fully charged and the service date was 05/07/2026. LPA did not

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NAME OF LICENSING PROGRAM MANAGER: Rita Ramos
NAME OF LICENSING PROGRAM ANALYST: Elicia Calvillo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
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: SIRIWARDANA FAMILY CHILD CARE
FACILITY NUMBER: 197495097
VISIT DATE: 06/24/2026
NARRATIVE
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a fireplace or any open-faced heaters. There is adequate heating and ventilation for safety and comfort. An emergency fire/disaster drill has not been completed within the last 6 months, and the documentation of the fire/disaster drill was readily available upon request showed last fire/disaster drill completed 06/11/2026. There is telephone service via a landline.

LPA did not observe a swimming pool or other similar bodies of water. Licenses stated there are no pets on the premises. LPA did observe any pets on the premises. Capacity as specified on the license is being maintained.

Per Assistant, there are no firearms or ammunition or other weapons on the premises; LPA did not observe any firearms or other weapons on the premises. Per Assistant, there are no poisons on the premises; LPA did not observe any poisons on the premises. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

LPA reviewed samples of children’s records and observed records are not complete and documented on LIC857. The record review found that 2 out 8 records did not contain a completed LIC282 Affidavit Regarding Liability Insurance, 4 out 8 records did not contain a completed Immunization Record, 3 of 8 records did not contain a completed LIC700 Identification and Emergency Information, 1 out of 8 records did not contain a completed LIC627 Consent for Emergency Medical Treatment, and 1 out of 8 records did not contain a completed LIC995A Notification of Parents’ Rights. One (1) Type B Citation for California Code of Regulations section 102418(g)(1) Immunizations was issued. LPA provided a copy of the PM286 form.

LPA reviewed the Licensee and Assistant records and observed the record are not complete and documented on LIC859. The record review found that 2 of 3 records did not contain a complete Immunization Record. One (1) Type B Citation for Health and Safety Code section 1597.622(c) Administration of Child Day Care Licensing was issued.

Licensee Pediatric CPR/First Aid expires 05/2028. Licensee’s Mandated Reported Training Certificate was completed 03/25/2026.

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NAME OF LICENSING PROGRAM MANAGER: Rita Ramos
NAME OF LICENSING PROGRAM ANALYST: Elicia Calvillo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
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: SIRIWARDANA FAMILY CHILD CARE
FACILITY NUMBER: 197495097
VISIT DATE: 06/24/2026
NARRATIVE
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All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Licensees were reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

There are currently three (3) infants enrolled at the facility. LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for and removing any 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.

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: https://www.ada.gov/resources/child-care-centers/.

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

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For

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NAME OF LICENSING PROGRAM MANAGER: Rita Ramos
NAME OF LICENSING PROGRAM ANALYST: Elicia Calvillo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
LIC809 (FAS) - (06/04)
Page: 7 of 8
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: SIRIWARDANA FAMILY CHILD CARE
FACILITY NUMBER: 197495097
VISIT DATE: 06/24/2026
NARRATIVE
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additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

During today’s visit, three (3) Type B citations were issued for California code or regulations and Health and Safety Code for sections 102417(a) Operation of A Family Child Care Home, 102418(g)(1) Immunizations , and 1597.622(c) Administration of Child Day Care Licensing,

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Apsara Kandaudage, Assistant.

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NAME OF LICENSING PROGRAM MANAGER: Rita Ramos
NAME OF LICENSING PROGRAM ANALYST: Elicia Calvillo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
LIC809 (FAS) - (06/04)
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