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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018616
Report Date: 08/22/2024
Date Signed: 08/22/2024 02:17:44 PM

Document Has Been Signed on 08/22/2024 02:17 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:JAYAWARDENA FAMILY CHILD CAREFACILITY NUMBER:
198018616
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
08/22/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Mary Jayawardena, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analysts (LPAs) Portia Bowden and Jeanette Estrada conducted an unannounced annual required inspection at the above facility on 08/22/24 at 11:45 AM. The facility is also being evaluated for a capacity increase during this inspection. An approved fire clearance was approved on 07/24/24. LPAs met with Licensees Mary & Anura Jayawardena who guided analysts on a tour of the facility. There were 8 children and three adults present when LPAs arrived. Facility capacity is in compliance for a Small Family Child Care Home. Hours of operation are Mon-Fri 7:30 AM - 6:00PM.

This is a one story home which consists of four bedrooms and two bathrooms. Areas used by the children include the living room, two rooms off living room (daycare rooms 1 & 2) one bathroom, and backyard. Per Licensees, areas off limits to children and parents include: all bedrooms, one bathroom, kitchen, dining area, front yard and garage. Children bring food from home, facility supplies AM and PM snacks as well as drinks (water,milk) LPAs observed food labeled with the child’s name and properly refrigerated in daycare room 2.

Individuals residing in the home have been discussed and noted. All adults present in the home have obtained a criminal record clearance or exemption. All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. The following was observed and reviewed during this inspection:
At 12:00 PM LPAs reviewed required posted documentation for Facility License and Publication (PUB) 394- Notification of Parent Rights. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted August 6th 2024.

At 12:05PM Smoke/carbon monoxide detector was tested and are operable. Fire extinguisher indicated fully charged, however and the receipt proved it was purchased April 23 2024. The home maintains telephone service via cell phone.
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SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Portia Bowden
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JAYAWARDENA FAMILY CHILD CARE
FACILITY NUMBER: 198018616
VISIT DATE: 08/22/2024
NARRATIVE
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At 12:07PM LPAs observed a 2A10BC Fire extinguisher in Daycare room 2 fully charged with purchase date of April 23, 2024

At 12:08 PM LPAs observed two cribs in living room as well as cots for sleeping. Per licensee all Detergents, cleaning compounds and medication are kept in off areas (kitchen) and inaccessible to children. Licensee understands that all poisons must be lock and inaccessible to children. Isolation area for sick children waiting to be picked up is in the daycare room 2 adjacent to daycare room 1, away from the other children. Per Licensee there are no firearms or weapons stored in the home .LPAs observed Daycare rooms 1 and 2 to be clean, orderly and contain age appropriate toys and learning materials. There were no fireplaces or wall heaters in the home. Home is equipped with Central heating and cooling.

At 12:10PM LPAs observed 8 children in backyard area. The outdoor play area was observed to be fenced. LPAs observed that the outdoor yard has toys and other materials for children to play with. At 12:15PM LPAs observed several rose bushes with thorns that could be hazardous to children in care. LPAs also observed a white rabbit in the backyard. Per licensee it is their family pet. At 12:17PM LPAs observed a water play station for children that was empty,There are no pools or spas, or other bodies of water. Licensee was reminded to immediately empty water after each play. At 12:20PM LPAs observed an detached garage that is off limits. At 12:21 LPAs observed an AC unit along side of home barricaded by gate.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunization Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, and documentation of 15 minute Infant Sleep Check (0-24 months). 2 out 2 children were missing current sleep log. Sleep log on file was not completed daily since August 12th, 2024. Per Licensee both children have been present at daycare. 1 out 2 was missing an LIC 9227 (infant Sleep plan).
Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, Proof of immunization against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate. 1 out of 3 staff members were missing mandated reporter training. Licensee's maintain current CPR First Aid Certification, issued by American Heart Association, however it was labeled as K-12 not Pediatric.
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SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Portia Bowden
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
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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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JAYAWARDENA FAMILY CHILD CARE
FACILITY NUMBER: 198018616
VISIT DATE: 08/22/2024
NARRATIVE
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Currently Licensee has two infants enrolled. LPAs discussed the safe sleep regulations with the 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

Licensee was reminded that all adults 18 and over living or working in the home, 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.
LPAs 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.

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 Anura Jayawardena confirmed that there are no Registered Sex Offenders living in the facility and LPAs completed the RSO in FAS.


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SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Portia Bowden
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
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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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JAYAWARDENA FAMILY CHILD CARE
FACILITY NUMBER: 198018616
VISIT DATE: 08/22/2024
NARRATIVE
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The following Deficiencies were noted during today's inspection:

Type B: Operation of family childcare home: Rose bush Thorns outside
Type B: Infant Sleep plan/ Infant Log
Type B: Mandated Reporter
Type B: Pediatric First Aid CPR Certification

A large license would be issued upon the department's approval.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site inspection by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted and report reviewed with the Licensee, Anura Jayawardena.
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Portia Bowden
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 08/22/2024 02:17 PM - It Cannot Be Edited


Created By: Portia Bowden On 08/22/2024 at 01:24 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: JAYAWARDENA FAMILY CHILD CARE
FACILITY NUMBER: 198018616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
102425(j)(2)The provider shall supervise infants while they are sleeping and adhere to the following requirements:
(D)Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:
a. Date.
b. Infant’s name.
c. Time of each 15-minute check.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 infant files did not contain a current infant sleep log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Licensee will document infant sleep log, copies of infant sleep log for week of 8/22-8/29/24 will be submitted to LPA
Type B
Section Cited
CCR
102425(c)
102425(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out 2 infants did not have an LIC 9227 (Infant Sleep Plan) on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Licensee will submit infant sleep plan completed by parents to LPA by POC 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.
SUPERVISOR'S NAME:Karen Chambers
LICENSING EVALUATOR NAME:Portia Bowden
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2024 02:17 PM - It Cannot Be Edited


Created By: Portia Bowden On 08/22/2024 at 01:43 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: JAYAWARDENA FAMILY CHILD CARE
FACILITY NUMBER: 198018616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)
102417 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 be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in there are rose bushes with protruding thorns in a flower bed in the outdoor playyard where children play with no visible barrier, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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Licensee will provide of inaccessible rose bushes and submit to LPA by POC due date.
Type B
Section Cited
CCR
102416(c)
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

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 2/2 Staff Who did not have Valid Pediatric First Aid CPR certification. Certification on file was labled as K-12 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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Licensee will submit proof of appointment for Pediatric First Aid CPR Certificatiion for both licensee's by POC due date 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:Karen Chambers
LICENSING EVALUATOR NAME:Portia Bowden
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


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Document Has Been Signed on 08/22/2024 02:17 PM - It Cannot Be Edited


Created By: Portia Bowden On 08/22/2024 at 01:51 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: JAYAWARDENA FAMILY CHILD CARE
FACILITY NUMBER: 198018616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
1596.8662(b)(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
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Based on record review, the licensee did not comply with the section cited above in 1 out of 3 staff did not have Mandated Reporter Training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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Licensee will submit Current proof of Mandated Reporter training to LPA by POC due date.
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:Karen Chambers
LICENSING EVALUATOR NAME:Portia Bowden
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


LIC809 (FAS) - (06/04)
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