198018616-6-25-2026-54-CC-ELUN-DVDUYS-20260625160026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198018616
Report Date: 06/25/2026
Date Signed: 06/25/2026 04:00:45 PM

Document Has Been Signed on 06/25/2026 04:00 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 CARE		FACILITY NUMBER:	198018616
ADMINISTRATOR/ DIRECTOR:	JAYAWARDENA, M&A		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(310) 356-7795
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 7	DATE:	06/25/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:40 PM
MET WITH:	Anura and Mary Jayawardena Licensees		TIME VISIT/ INSPECTION COMPLETED:	04:15 PM

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On June 25, 2026 at 1:40 p.m. Licensing Program Analysts (LPA) Erica Lujan conducted an Unannounced Annual inspection to the above facility. LPA disclosed the purpose of the inspection and met with Licensee, Anura and Mary Jayawardena who guided the LPA on a tour of the facility.

All adults in the home were found to have criminal record clearance. Licensee states that there are currently 7 children enrolled. The children's roster was reviewed and is current. During the inspection, 7 children (1 infant and 6 preschool age children) 1 assistant, and Licensees Anura and Mary were present during inspection. LPA observed 7 children napping. Licensee reports that the facility’s hours of operation are 7:30 AM to 6:00 PM, Monday thru Friday. Emergency Disaster Plan, License, and Parents’ Rights were posted at the time of inspection. Per Licensee, disaster drill was last conducted on 06/09/2026.

This is a single-story home which consists of three bedrooms, two bathroom, kitchen, living/dinning room, family room and front/back yard. Areas used by the children include the living room, family room, bedroom 1, and bathroom 1. Living room will be used for isolation of sick children. Per Licensee, areas off limits to children and parents include kitchen, bathroom 2, bedroom 2, and bedroom 3. LPA observed that there is a barricade making it inaccessible to children in care at time of inspection. Per licensee, off limit bedrooms are locked during operating hours, LPA observed doors to be locked.

All areas identified on the facility sketch as accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for the safety of the children. Main Care Areas for the day care children is located in family room and bedroom 1 which is equipped with toddler tables/chairs for activities,

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NAME OF LICENSING PROGRAM MANAGER: Karen Chambers
NAME OF LICENSING PROGRAM ANALYST: Erica Lujan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026

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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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: 06/25/2026

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dramatic play corner, reading area, art center, cubbies with manipulative toys and activities for a variety of ages. Bedroom 1 has a small table and chairs with age-appropriate toys and push toys. LPA observed diaper changes with changing table and cubbies with diapers and supplies. LPA observed cots and one crib. Per Licensee, linens are washed at facility. LPA observed central A/C and heating throughout the home. There is a working telephone maintained in the home.

Per licensee, the children will have access to back for outside play. LPA observed yard has grass and adequate perimeter fencing through-out the property. LPA observed backyard free of loose and sharp parts available for the children in the yard and all trees, shrubs, and plants are maintained. LPA observed age-appropriate toys, monkey bars toddler gym, slide, toddler bikes, and sandbox for outside play.

The valve on the required 2A 10BC fire extinguisher indicates fully charged, proof of purchase date reflects date of 09/12/2025. LPA checked Smoke and carbon monoxide detectors are in operable condition at time of inspection. Hazardous items including poisonous cleaning compounds were stored in the garage which is inaccessible area to children. LPA observed First Aid kit kept on shelf in Main Care Area and was inventoried for necessary supplies. Licensee provided proof of immunization against influenza, pertussis, and measles during today’s inspection. Licensees and assistance have current mandated reporter training and cpr.

__ Mandated Reporter valid until: 06/2024-06/2026

—CPR Card valid until: 10/29/2024-10/2026

—3 out of 7 Children records were reviewed and in compliance with all required licensing forms. All required licensing forms were discussed with Licensee as well as mandated child abuse reporting and criminal record clearance requirement.

Per Licensee, there are no weapons, firearms in the home and there are no bodies of water around the premises. LPA did not observe any bodies of water around the premises at time of inspection. Per licensee, they provide food for some children in care and also allow children to bring food from outside. LPA observed all food boxes were label with each child’s name in the refrigerator. Licensee provides breakfast, lunch and am and pm snacks. Food preparation area was toured and found in compliance for safety, cleanliness, and proper storage.

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NAME OF LICENSING PROGRAM MANAGER: Karen Chambers
NAME OF LICENSING PROGRAM ANALYST: Erica Lujan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026

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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JAYAWARDENA FAMILY CHILD CARE	FACILITY NUMBER: 198018616
	VISIT DATE: 06/25/2026

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LPA reviewed with licensee the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the licensee.

The following were 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 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-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 2202-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) 5140383 (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/.

The facility was found in compliance per Title 22 regulations, there will be no deficiencies cited today 06/25/2026.

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.

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NAME OF LICENSING PROGRAM MANAGER: Karen Chambers
NAME OF LICENSING PROGRAM ANALYST: Erica Lujan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026

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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JAYAWARDENA FAMILY CHILD CARE	FACILITY NUMBER: 198018616
	VISIT DATE: 06/25/2026

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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.

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

Exit interview conducted and report was reviewed with the Licensee Anura Jayawardena.

NAME OF LICENSING PROGRAM MANAGER: Karen Chambers
NAME OF LICENSING PROGRAM ANALYST: Erica Lujan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026

LIC809 (FAS) - (06/04)

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