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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018616
Report Date: 07/13/2021
Date Signed: 07/13/2021 02:57:44 PM

Document Has Been Signed on 07/13/2021 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:JAYAWARDENA FAMILY CHILD CAREFACILITY NUMBER:
198018616
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
07/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Mary Jayawardena TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Raul Navarro conducted an unannounced random annual inspection. LPA arrived at 1:04pm and met with Licensees Mary and Anura Jayawardena who guided this LPA on a tour of the facility. There was one child present during today’s inspection. Licensee's states that there are currently two children enrolled. The Licensees are within the conditions, limitations, and capacity specified on the license. The children's roster was reviewed and is current.

This is a one story home which consists of four bedrooms and two bathrooms. Areas used by the children include the activity area, napping area, one bathroom, and backyard. Per Licensees, areas off limits to children and parents include: all bedrooms, one bathroom, living room, kitchen, dining area, front yard and garage. Outdoor play area is fenced. The Licensees uses the bedroom near the activity area as the designated ill isolation area.

Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for the safety of the children. There is a working telephone service maintained in the home. All adults present in the home have obtained a criminal record clearance or exemption prior to working, residing or volunteering in the licensed childcare home. Licensees have a pet dog. Detergents, cleaning compounds, medications, and other items which can pose a danger to children are inaccessible. The Licensees do understand that poison must be locked with a key or combination lock.

Per Licensees, there is a firearm in the home. Firearm is kept in a safe. Ammo is stored in a separate locked safe as required. There are no bodies of water on the premises. There are safe toys, play equipment and materials observed for children. Emergency Disaster Plan was posted at the time of inspection. At 11:31pm, LPA observed the valve on the required 2A 10BC fire extinguisher indicated fully charged, however, it was last purchased in 2019.
Report continues- Page 1 of 3
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Raul Navarro
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2021
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JAYAWARDENA FAMILY CHILD CARE
FACILITY NUMBER: 198018616
VISIT DATE: 07/13/2021
NARRATIVE
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Smoke and carbon monoxide detectors were tested and are in operable condition. The Licensees have current EMS approved Pediatric First Aid and CPR, which will expire on 02/2022. Proof of immunization against influenza, pertussis, and measles for the Licensees and was readily available during today’s inspection. The Licensees have not taken the mandated reporter due to training not being available in their primary language.

Licensees state that they are not currently caring for infants. Licensees state that if an infant is enrolled, the infant will sleep in the napping area where they are constantly supervised. Appropriate sleeping arrangements and cribs were observed. Crib did not hinder the entrance or exit from the sleeping space, mattress was firm and covered with a fitted sheet that overlaps the underside so it cannot be dislodged. Crib was observed to be free of loose articles and objects. No objects were observed to be hanging above or attached to the side of the crib. LPA did not observe any infants swaddled while in care. LPA advised the Licensees that infants shall be placed on their backs for sleeping and shall be supervised. Infants shall be checked on every 15 minutes and the time of each 15 minute check shall be documented with child’s name and date. The LIC 9227 Individual Infant Sleeping Plan shall be completed for each infant up to 12 months of age. A copy of the LIC 9227 was provided to Licensee.

The following was discussed: Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty. The Licensee shall be present in the home and shall ensure that children in care are supervised at all times. When temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise children in their absence.

Rooms that are off-limits need to be made inaccessible during operating hours. Smoking is prohibited in a licensed Family Child Care Home. Infant walkers, johnny jumpers, saucer chairs, trampolines and any other item that falls into that category are not permitted in the facility. Car seats shall only be used for transportation purposes and shall not be used for sleeping. Effective January 1, 2010, licensees of family child care homes are required to ensure that at least one staff member with current training in pediatric first aid and pediatric CPR is on site at all times when children are present.
Report continues- Page 2 of 3
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Raul Navarro
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021
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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JAYAWARDENA FAMILY CHILD CARE
FACILITY NUMBER: 198018616
VISIT DATE: 07/13/2021
NARRATIVE
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LPA reviewed the LIC 311D - Forms/Records to Keep in Your Family Child Care Home. Role and responsibilities of being a Mandated Reporter were reviewed. The Licensee was advised how to access forms and Regulations online at www.ccld.ca.gov. Licensees were made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care.

The Licensees were advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Sudden Infant Death Syndrome (SIDS) and Never-Shake-a-Baby were discussed. A hard copy of A Child Care Provider’s Guide to Safe Sleep was provided.

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 Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Children’s Records were reviewed to ensure that Identification and Emergency form and a medical assessment are on file. LPA issued the Confidential Names List (LIC 811) to the Licensees during this visit. The Confidential Names List documents the children’s files that were reviewed during this inspection.

The deficiency listed on the following page was observed by the LPA and is being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D. The deficiency that is being cited needs to be cleared to protect the children’s health & safety

Exit interview was conducted with Licensees Mary and Anura Jayawardena. The Licensees were provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these forms. 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.

Report ends- Page 3 of 3
SUPERVISORS NAME: Karen Chambers
LICENSING EVALUATOR NAME: Raul Navarro
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/13/2021 02:57 PM - It Cannot Be Edited


Created By: Raul Navarro On 07/13/2021 at 01:55 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: 07/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2021
Section Cited
CCR
102417(g)(1)

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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: (1)The home shall contain a fire extinguisher... which meet standards established by the State Fire Marshal. This
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Licensee will purchase a new fire extinguisher and submit proof of purchase to LPA by the POC date of 7/27/21.
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requirement was not met as evidenced by Licensee statement. Per Licensee, fire extinguisher was last purchased in 2019. This poses a potential risk to the health and safety of the children in care.
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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:Raul Navarro
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2021


LIC809 (FAS) - (06/04)
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