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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312178
Report Date: 12/03/2021
Date Signed: 12/03/2021 11:32:28 AM

Document Has Been Signed on 12/03/2021 11:32 AM - 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:SILVA, HEMAMALIFACILITY NUMBER:
304312178
ADMINISTRATOR:SILVA, HEMAMALIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 400-2268
CITY:FOOTHILL RANCHSTATE: CAZIP CODE:
92610
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
12/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Hemamali Silva, LicenseeTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) P Rivas conducted an unannounced case management visit to issue citations observed during today's visit.. Prior to entrance LPA conducted Risk Assessment. Upon entrance there were seven children present. At 9:30am Ms. Silva had son Dinushka Silva assist while Ms. Silva assisted LPA.
LPA reviewed Facility Personnel Summary and found individuals requiring fingerprint clearances had them as required.

During interview with Licensee, LPA was advised of one child who stopped attending program mid November. Upon review of Child Care Facility Roster (lic9040) LPA could not locate child's name on roster.
Licensee advised LPA " I justy really just missed it."

The following deficiency is cited under the California Code of Regulations Title 22 Division 12 Chapter 1 (on following page)

An exit interview conducted with licensee. Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2021
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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Document Has Been Signed on 12/03/2021 11:32 AM - It Cannot Be Edited


Created By: Pat Rivas On 12/03/2021 at 11:00 AM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SILVA, HEMAMALI
FACILITY NUMBER: 304312178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2021
Section Cited
CCR
102417(g)8

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Operation of a Family Child Care Home
The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to:Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
This requirement was not met as
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Licensee updated roster during visit
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evidenced by LPA's review of child care facility roster and Licensee's statement that she"...just really missed it." This poses a potential risk to 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:Rina Lopez
LICENSING EVALUATOR NAME:Pat Rivas
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2021


LIC809 (FAS) - (06/04)
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