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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017352
Report Date: 02/20/2025
Date Signed: 02/20/2025 02:57:39 PM

Document Has Been Signed on 02/20/2025 02:57 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:JAYAWARDENE FAMILY CHILD CAREFACILITY NUMBER:
198017352
ADMINISTRATOR/
DIRECTOR:		NISHALA JAYAWARDENEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 220-8781
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 11DATE:
02/20/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Licensee - Nishala JayawardeneTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) R. Derraco conducted an unannounced annual inspection to the above facility on 02/20/25. LPA arrived at the facility at 12:15 PM and met with licensee, Nishala Jayawardene, who guided analyst on a tour. Also present during this inspection was an assistant S1. Per Licensee, there are 12 children that are currently enrolled. There were 11 children present upon arrival.

This is a one-story home which consists of 3 bedrooms, 3 bathrooms, kitchen/dining room, living room, den a detached garage, front yard and backyard (fenced). The off limit areas include 3 bedrooms, 2 bathrooms, detached garage, and front yard.

The main care are is located in the den. LPA observed age appropriate toys, wall mounted television, child sized tables and chairs, a play yard, and 4 Graco pack and play playpens. A tension gate was observed at the entrance to the main care area to the kitchen/dining area. Tension gates were also observed in the main care area. Per licensee, isolation area for children showing signs of illness will be located in the middle section of the main care area. The kitchen/dining area was observed with a child sized table and chairs. Per licensee, children take meals in the kitchen/dining area and are immediately brought to the main care area after their meal. Licensee states that she provides food for children in care. LPA advised licensee that children who bring food must have separate containers that are labeled and properly stored or refrigerated. Objects that are sharp or have pointy parts were observed to be inaccessible in a cabinet above the kitchen counter. Cleaning supplies were observed to be locked beneath the kitchen sink. The living room was observed with a couch, coffee table and a fire place. LPA observed that the fire place does not have a cover with a lock. LPA advised licensee that a Type B citation will be issued under California Code of Regulation (CCR) section 102417(g)(1). The bathroom was observed to have an operable sink faucet and toilet. The outdoor play area was observed to have additional age appropriate toys, dramatic play sets, a wooden cubby locker for personal belongs, outdoor play equipment and child sized climbing structures. LPA observed perimeter
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SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Randy Derraco
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 02/20/2025 02:57 PM - It Cannot Be Edited


Created By: Randy Derraco On 02/20/2025 at 02:15 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JAYAWARDENE FAMILY CHILD CARE
FACILITY NUMBER: 198017352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

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 clean the backyard play area which poses a potential Health, safety and/or personal rights risk to persons in care.
POC Due Date: 03/03/2025
Plan of Correction
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Licensee states she will send LPA a picture of the cleaned back yard play area
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

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 screen the fireplace to prevent access by children which poses and potential Health, safety and/or personal rights risk to persons in care.
POC Due Date: 03/03/2025
Plan of Correction
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Licensee states she will send LPA a picture of the fire place with a screen.
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:Denise Gibbs
LICENSING EVALUATOR NAME:Randy Derraco
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 02/20/2025 02:57 PM - It Cannot Be Edited


Created By: Randy Derraco On 02/20/2025 at 02:15 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JAYAWARDENE FAMILY CHILD CARE
FACILITY NUMBER: 198017352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

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 store poisons and other items in a locked area. which poses a potential Health, safety and/or personal rights risk to persons in care.
POC Due Date: 03/03/2025
Plan of Correction
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Licensee states she will send LPA a picture of the area where she stores poisons and other items that could pose a danger to children in care.
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 and record review, the licensee did not maintain documentation for S2 which poses a potential Health, safety and/or personal rights risk to persons in care.
POC Due Date: 03/03/2025
Plan of Correction
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Licensee states she will send LPA a copy of S2's immunization records.
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:Denise Gibbs
LICENSING EVALUATOR NAME:Randy Derraco
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/20/2025 02:57 PM - It Cannot Be Edited


Created By: Randy Derraco On 02/20/2025 at 02:15 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JAYAWARDENE FAMILY CHILD CARE
FACILITY NUMBER: 198017352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, S2 did not complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866 which poses a potential Health, safety and/or personal rights risk to persons in care.
POC Due Date: 03/03/2025
Plan of Correction
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Licensee states she will send LPA a copy of EMSA approved pediatric first aid and CPR Training certificate.
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.
SUPERVISOR'S NAME:Denise Gibbs
LICENSING EVALUATOR NAME:Randy Derraco
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JAYAWARDENE FAMILY CHILD CARE
FACILITY NUMBER: 198017352
VISIT DATE: 02/20/2025
NARRATIVE
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fencing and shade through the backyard play area. A sliding gate was observed at the top of the steps from the patio to the outdoor play area. Pet feces was observed on ground of the outside play area. LPA advised licensee that a citation under CCR section 102417(g) will be issued. LPA observed a storage shed without doors located in the outdoor play area to contain insect killer and anti freeze bottles. LPA advised licensee that citation under CCR section 102417(g)(4)(A) will be issued. LPA also advised the storage areas for poisons such as insect killer and anti-freeze must be locked, not just made inaccessible. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted in the main care area.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety,
comfort, and cleanliness. There is telephone service via a cellphone that is used and the cellphone stays at the facility during operation hours. Per Licensee, the home is equipped with central heating and air conditioning. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was purchased on 07/15/24, as indicated on receipt. Smoke and carbon monoxide detectors were tested and are operable. No bodies of water were observed in the back yard play area. Per licensee, she has a pet dog. Licensee states that there are no firearms stored in the home. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.

The licensee has completed training on preventive health practices including Pediatric First Aid and CPR. LPA observed S2 to have a pediatric first aid and CPR training certificate without an EMSA sticker. Per S2, the training was completed online. LPA advised licensee that a citation under 102416(c) will be issued. LPA observed that the Licensee and assistant do have proof of the Mandated Reporter AB 1207 compliant Child Care Training Certificate on file. File review was observed to have proper mandated immunization records for the licensee. LPA observed that S2's personnel file did not include a copy of mandated immunization records. LPA advised licensee that a citation under Health and Safety Code (HSC) section 1597.622(c) will be issued. Children’s records were reviewed, including emergency information and were observed to be complete. A current children’s roster was available for review.

Individuals who reside in the home were noted and discussed. 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
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SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Randy Derraco
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JAYAWARDENE FAMILY CHILD CARE
FACILITY NUMBER: 198017352
VISIT DATE: 02/20/2025
NARRATIVE
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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.

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-and-resources/safe-sleep as an additional resource. 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.

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/.

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

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.

LPA advised the licensee to access forms, regulations and quarterly updates online at: www.cdss.ca.gov.

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

(page 3 of 4)
SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Randy Derraco
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JAYAWARDENE FAMILY CHILD CARE
FACILITY NUMBER: 198017352
VISIT DATE: 02/20/2025
NARRATIVE
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children’s health & safety.

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

Exit interview conducted and report was reviewed with the licensee Nishala Jayawardene.


(page 4 of 4)
SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Randy Derraco
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
Page: 7 of 7