198014774-5-19-2026-58-CC-ECAO-DU8PRN-20260519113300

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198014774
Report Date: 05/19/2026
Date Signed: 05/19/2026 11:33:36 AM

Document Has Been Signed on 05/19/2026 11:33 AM - 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:	MATARAARACHCHI FAMILY CHILD CARE		FACILITY NUMBER:	198014774
ADMINISTRATOR/ DIRECTOR:	MATARAARACHCHI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 521-8446
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 13	CENSUS: 11	DATE:	05/19/2026
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:35 AM
MET WITH:	Janitha Mataraarachchi,Licensee		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/18/2026, Licensing Program Analyst (LPA) Elicia Calvillo conducted an unannounced 3 Year Annual inspection at 837 N. Pass Avenue, Burbank, CA. 91505. LPA arrived at the facility at 08:35 AM, identified self and met with Janitha Mataraarachchi, Licensee, who guided analyst on a tour of the inside and outside of the facility. There were eleven (11) children in care, one (1) Assistant, and one (1) adult resident present at arrival. LPA provided Licensee with a copy of the LIC126 Entrance Checklist to help facilitate the inspection. Facility operation hours are Monday to Friday from 8:00AM to 05:45PM. The family child care home is two story dwelling with a living room, dining room, kitchen, family room, office, sunroom, laundry, five (5) bedrooms, five and half (5 1/2) bathrooms, and attached garage. There is a front yard used for dropping off and picking up children and a fenced outdoor play area in the back yard. The children enter and exit the child care home from the living room front door. LPA observed the family room and bathroom #1 is used for child care and accessible to parents and children. LPA observed the family room is used for child activities, group time, eating, and sleeping. LPA observed thirteen (13) chairs, three (3) tables, toys, play items that were safe, clean, and appropriate for the ages of the children. LPA play yards, cots, and bed linens that are provided by parents and/or Licensee. LPA observed in the family room, there are individual baskets with diapers labeled with each child’s name. LPA observed the children will have access to bathroom #1 located near the family room. LPA observed Page 1 of 4

NAME OF LICENSING PROGRAM MANAGER: Rita Ramos
NAME OF LICENSING PROGRAM ANALYST: Elicia Calvillo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

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 05/19/2026 11:33 AM - It Cannot Be Edited

Created By: Elicia Calvillo On 05/19/2026 at 10:57 AM

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: MATARAARACHCHI FAMILY CHILD CARE	FACILITY NUMBER: 198014774
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2026

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
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 2 staff records did not contain a current Mandated Reporter Certificate readily availabe upon request which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2026
	Plan of Correction
1 2 3 4	Licensee stated that Licensee and Assistant will complete the Mandated Reporter Training and provide LPA with a copy of the completed certificate by the plan of correction due date 06/02/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

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: MATARAARACHCHI FAMILY CHILD CARE	FACILITY NUMBER: 198014774
	VISIT DATE: 05/19/2026

NARRATIVE

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there is a pedestal sink and the bathroom children will use was safe, sanitary and no hazards were present.

The outdoor play area is located in the back of the house, is fenced and there are no hazards to children present. LPA observed there are toys and play equipment that are free of sharp pointed parts, in good repair, and appropriate for the ages of the children.

Licensee stated that when a child shows signs of an illness the child will be isolated in dining room, away from the other children.

The family child care home is two story dwelling with the living room, dining room, kitchen, office, sunroom, laundry, five (5) bedrooms, five (5) bathrooms, and attached garage that are off-limits to parents and children. These rooms are made inaccessible by use of a door lock to the only entrance into bedrooms on the first floor, child proof gates at the entrance to the second floor, and child proof gates at the family room entrance.

There is telephone service via a cellphone. LPA advised Licensee that if a cellphone is used it must remain in the child care home during the operation hours.

There is a fire alarm on the wall near the kitchen. There is a carbon monoxide detector on the ceiling in the hallway near the kitchen and it 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 02/04/2025. LPA did not observe a fireplace or any open-faced heaters. There are adequate heating and ventilation for safety and comfort. An emergency fire/disaster drill has been completed within the last 6 months on 05/18/2026 and the documentation of the fire/disaster drill was readily available upon request.

LPA did not observe any pools, spas, hot tubs, fish ponds, or similar bodies of water during the inspection on the property.

Licensee stated there are no pets on the premises. LPA did not observe any pets in the facility.

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NAME OF LICENSING PROGRAM MANAGER: Rita Ramos
NAME OF LICENSING PROGRAM ANALYST: Elicia Calvillo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

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: MATARAARACHCHI FAMILY CHILD CARE	FACILITY NUMBER: 198014774
	VISIT DATE: 05/19/2026

NARRATIVE

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Per Licensee, 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 Licensee, there are no poisons in the home and LPA did not observed any during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

Licensee was reminded that children in care are to be supervised at all times and made aware that children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children.

Capacity as specified on the license is being maintained.

LPA reviewed samples of children’s records and observed files are complete and documented on the LIC857. LPA reviewed the Assistant records and observed file is complete and document on the LIC859. Licensee’s Mandated Reporter Training was expired and a certificate of completion readily available upon request. Licensee’s pediatric CPR/First Aid expires on 07/2026.

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.

Licensee was 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. 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
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NAME OF LICENSING PROGRAM MANAGER: Rita Ramos
NAME OF LICENSING PROGRAM ANALYST: Elicia Calvillo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

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: MATARAARACHCHI FAMILY CHILD CARE	FACILITY NUMBER: 198014774
	VISIT DATE: 05/19/2026

NARRATIVE

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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 Janitha Mataraarachchi, Licensee, 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 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, one (1) type B Citation is issued for section 1596.8662(b)(1) 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 Janitha Mataraarachchi, Licensee.

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NAME OF LICENSING PROGRAM MANAGER: Rita Ramos
NAME OF LICENSING PROGRAM ANALYST: Elicia Calvillo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

LIC809 (FAS) - (06/04)

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