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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198401330
Report Date: 09/15/2025
Date Signed: 09/15/2025 02:13:00 PM

Document Has Been Signed on 09/15/2025 02:13 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:KEERTHISINGHE FAMILY CHILD CAREFACILITY NUMBER:
198401330
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
09/15/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:48 AM
MET WITH:Applicant- Harshani KeerthisingheTIME VISIT/
INSPECTION COMPLETED:
02:23 PM
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On September 15, 2025, at 11:48a.m., Licensing Program Analyst (LPA) Keneisha Dunlap arrived at the above facility for the purpose of an announced Pre-Licensing inspection. LPA Dunlap announced the purpose of the visit and was granted entry into the home by Applicant- Harshani Keerthisinghe. Per the Applicant, hours of operation will be Monday- Friday 7:00 a.m. to 6:00 p.m. The Applicant will serve children ages 0 to 12 years of age.

This single-story home includes a living room, four bedrooms, three bathrooms, a kitchen, fenced backyard, and front yard, and garage. The main care areas are the living room, dining room, bedroom 1, bathroom 1, and fenced back yard. All accessible areas were inspected for cleanliness, health, safety, heating, and ventilation.

Off limits area: Kitchen, three bedrooms, two bathrooms, garage, and front yard.

All off limit areas with doors have safety doorknob covers.

Living Room (Main Care Area): This area features carpeted area with area rugs. A mounted TV, various play areas: dramatic play, library, math, science, and manipulative play. Age-appropriate tables and chairs, Soft plush furnishings, and a playpen. A baby gate blocks this area. All furnishings, equipment, and materials were found to be in good condition.

Bedroom One: This area features tile floor with area rug. There are four cribs and a changing station. The children will nap in this area, and there are also mats stored here. There is a closet in this space that houses learning materials for the facility. Page 1 of 4

NAME OF LICENSING PROGRAM MANAGER: Karen Chambers
NAME OF LICENSING PROGRAM ANALYST: Keneisha Dunlap
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2025
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 5
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: KEERTHISINGHE FAMILY CHILD CARE
FACILITY NUMBER: 198401330
VISIT DATE: 09/15/2025
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Bathroom: This area is in the same room as Bedroom One. The bathroom cabinet has handwashing supplies, toilet paper, and paper towels available. The sink and toilet are operable, and the bathroom floor is free of hazards. There is a potty chair in this area. There are no safety latches on the cabinets and/or medicine cabinet. The Applicant informed LPA Dunlap that the personal hygiene items, medications, and/or cleaning products are stored in the garage area and/or off limits bathroom making it inaccessible to children.

Kitchen Area: A baby gate blocks the kitchen entrance. The knives are stored in a high cabinet making them inaccessible to children. There are stove knob covers on oven. There are no safety latches on cabinets. The Applicant informed LPA Dunlap that all the cleaning products and/or hazardous materials are stored in the garage area making it inaccessible to children.

Dining Room: This area features tile floors with soft mat cushions. There is a baby gate blocking off the area where children will eat. There are two highchairs, and age-appropriate chairs and tables.

The hallway leading to the off-limits areas has a baby gate blocking the entrance making it inaccessible to children.

Outdoor Play Area: The fenced backyard includes a retractable canopy for shade, artificial grass, a picnic table, and various age-appropriate toys and equipment (playhouse, balls, sand & water table, basketball court, small slide structure, and bikes). The equipment is in good condition, free of sharp, loose, or pointed parts.

LPA Dunlap observed the parent board by the front door of the home. LPA informed the Applicant of the required department documents that need to be posted:


· Parent's Rights (PUB 394)
· Earthquake Preparedness Checklist (LIC9148)

The home is ventilated by HVAC system.

An operable carbon monoxide was observed in the main care area and bedroom one.

An operable smoke detector was observed in the main care area and bedroom one.

A 2A 10BC fire extinguisher with a receipt date of August 31, 2025, was hung on the wall located in the main care area. Page 2 of 4

NAME OF LICENSING PROGRAM MANAGER: Karen Chambers
NAME OF LICENSING PROGRAM ANALYST: Keneisha Dunlap
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: KEERTHISINGHE FAMILY CHILD CARE
FACILITY NUMBER: 198401330
VISIT DATE: 09/15/2025
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The Applicant has a cell phone for communication.

A first aid kit is available.

No firearms or ammo are present in the home.

No smokers are present in the home.

Exposed electrical outlets throughout the home are covered.

The Applicant will provide food for children and was reminded to be mindful of serving food to children with food allergies.

The Applicant does not plan to administer medication at this time.

Sick children will be isolated in Bedroom One.

The Applicant will provide transportation.

No pets are present in the home.

There are no large bodies of water on the premises.

Applicant- Harshani Keerthisinghe was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.



Because the Applicant- Harshani Keerthisinghe rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

LPA reviewed with Applicant- Harshani Keerthisinghe the LIC 311D, Forms/Records to Keep In Your Family Page 3 of 4
NAME OF LICENSING PROGRAM MANAGER: Karen Chambers
NAME OF LICENSING PROGRAM ANALYST: Keneisha Dunlap
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: KEERTHISINGHE FAMILY CHILD CARE
FACILITY NUMBER: 198401330
VISIT DATE: 09/15/2025
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Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

LPA discussed the safe sleep regulations with Applicant- Harshani Keerthisinghe 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 Applicant- Harshani Keerthisinghe 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.

On this date, 09/09/2025, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant- Harshani Keerthisinghe was informed of the MyChildCarePlan.org site, 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication

A small/large Family Child Care Home license will be granted upon review by a Licensing Program Manager. Once licensed, the applicant is required to comply with the terms and limitations stated on the license.


Exit interview conducted and report was reviewed with the Applicant- Harshani Keerthisinghe. Page 4 of 4

NAME OF LICENSING PROGRAM MANAGER: Karen Chambers
NAME OF LICENSING PROGRAM ANALYST: Keneisha Dunlap
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC809 (FAS) - (06/04)
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