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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198401330
Report Date: 03/04/2026
Date Signed: 03/30/2026 03:47:49 PM

Document Has Been Signed on 03/30/2026 03:47 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: 6CENSUS: 5DATE:
03/04/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Licensee Harshani KeerthisingheTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 03/04/2026 at 1:20pm, Licensing Program Analyst (LPA) Jonnisha Culbert conducted an annual/random inspection at the facility noted above. LPA met with licensee, Harshani Keerthisinghe and stated the purpose of today's visit. The purpose of the visit is to inspect the home for a large family child care license. On 02/06/2026 the Department received an application from licensee requesting a capacity increase (large child care license). Fire clearance for the facility was approved on 02/24/2026. Individuals residing in the home were discussed and noted. Present during the inspection were licensee, assistant, and five children

This single-story home that includes a living room, four bedrooms, three bathrooms, a kitchen, fenced backyard, front yard, den, and garage.

Areas on limits to children are: one bedroom, living room, one bathroom, and den (through passing to get to the backyard).

Areas that are off-limits to children are: three bedrooms, two bathrooms, kitchen, and attached garage.

The following documents were posted: Facility License, Notification of Parents' Rights (PUB 394), and Earthquake Preparedness (LIC 9148).

Areas used by children were inspected for safety, comfort, heating, cleanliness, and telephone service. LPA observed outlets were covered by furniture, play yards, age-appropriate toys, toddler table and chairs, and vents. Per Licensee, the home is equipped with central heating and air. Cleaning supplies were kept inside a inaccessible cabinet under the sink in the kitchen. Other items (medications, knives) that pose a potential

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2026
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: KEERTHISINGHE FAMILY CHILD CARE
FACILITY NUMBER: 198401330
VISIT DATE: 03/04/2026
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safety risk to children were made inaccessible. Per licensee, there are no poisons on the premises. Licensee was reminded that if poisons are purchased, they are to remain in areas that are locked and inaccessible to children. Per licensee, there are no firearms or bodies of water on the premises.

LPA checked the home for required emergency devices. LPA observed a fire extinguisher (2-A:10-B:C) that is fully charged. LPA observed the extinguisher was purchased on 08/31/2025. LPA reminded licensee that the fire extinguisher shall be serviced yearly or repurchased. Carbon monoxide and smoke alarm were observed and are operable. The facility roster and disaster drill log were reviewed, and the last drill was conducted on 01/12/2026.

Per licensee, they provide meals and snacks for children in care. Licensee was reminded that food that is brought from the children's home shall be labeled with the child’s name and properly stored or refrigerated.

LPA conducted a record review of one child’s file and two personnel files. During record review, LPA observed that the child's file was complete. During personnel record review, LPA observed that staff files were complete. Licensee has a valid Pediatric First Aid/CPR/AED certificate that expires 05/2027, required immunizations, and a valid mandated reporter completion certificate (expires 08/17/2027). LPA reminded licensee that mandated reporter training must be completed every 2 years. Mandated reporter training is available at www.mandatedreporterca.com.

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.

The applicant provided proof of control of property.

This facility plans to provide Incidental Medical Services- IMS. For IMS information, see PIN 22-02-CCP. 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) or (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.

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2026
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: KEERTHISINGHE FAMILY CHILD CARE
FACILITY NUMBER: 198401330
VISIT DATE: 03/04/2026
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LPA reviewed with applicant the LIC 311D, Forms/records to Keep in your Family Child Home, 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 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 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, 02/23/2026, 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.

Licensee 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.

A notice of site visit was given to licensee, and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with the licensee, Harshani Keerthisinghe.

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.

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2026
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: 03/04/2026
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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.

If you have any questions regarding the processor CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and it's tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

No citations were issued during today's visit.

The licensee was notified that a license will be issued following the Department's review and approval of the application.

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2026
LIC809 (FAS) - (06/04)
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