304314040-7-26-2022-06-CC-KDEI-CGPUXD-20220726155810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304314040
Report Date: 07/26/2022
Date Signed: 07/26/2022 03:58:27 PM

Document Has Been Signed on 07/26/2022 03:58 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	MENDIS, APPUWAHANDI & CHRISTOFELSZ, SURESH		FACILITY NUMBER:	304314040
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	07/26/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Applicant Ms. Mendis, Appuwahandi		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Desai, Ketki conducted an announced in-person Pre-Licensing inspection for a new Small Family Child Care home. LPA met with the Applicant Ms. Mendis, Appuwahandi who provided a tour of the new home. A review of the Facility Personnel Report Summary indicates adult residents, who require caregiver background check clearances, transfers, exemptions have been obtained and they are cleared. Applicant stated, she is not currently registered with any Resource Foster Care agency or holds a Resource foster parent license. Applicant was reminded if changes, to notify the licensing office. Applicant is requesting for a Small family childcare home license. Operation hours will be Monday to Friday 6:00 AM to 6:00 PM and care and supervision shall be provided to children ages 3 months to 12 years only ( Infants to School age children only) All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a single story family home with 3 bedrooms, 2 bathrooms, living with dining area, kitchen, de- attached garage, front and back yard. Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone is the primary contact phone. Ventilation and heating. There is central heat in the home. Home has ceiling vents for air flow. The A/C unit is in the back yard ( inaccessible to children) Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children stored in the locked garage and top cabinets. The Applicant states (that there are no poisons on the premises). Applicant was advised that any poisons must be locked with a key or combination lock. (1)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

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 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MENDIS, APPUWAHANDI & CHRISTOFELSZ, SURESH	FACILITY NUMBER: 304314040
	VISIT DATE: 07/26/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on the Facility Sketch submitted, areas off limits to children and parents are: Applicant has designated , Kitchen, three bedrooms, one full bathroom, with de-attached garage as off limits areas. Applicant has made the kitchen inaccessible by installing a collapsible gate on one side facing the living area and second end with a wooden sliding door and all the lower cabinets have child safety locks installed on the cabinets. The three bedrooms have child safety door knobs installed along with a child safety gate installed at the end of the living area making the bedrooms and master bathroom inaccessible to children. There is no direct access to the Garage from the home. The A/C unit is in the side section of the back yard and this area is inaccessible to children. Applicant has fenced an area for outdoor activities.

There is no Fire place or stairway in the home.

During the Pre-licensing inspection, LPA observed the designated off limits areas were closed and locked.

Applicant shall use the Cell phone for Day care activities and applicant was informed if a cell phone is used for child care, it must remain on the premises at all times during hours of operation.

Applicant was informed and understands the home is to be free from smoking during hours of operation.
Applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

Areas Designated for Day care activities: Parents and children shall enter the home, through the main gate of the home through the front yard, there is metal sliding gate making the front entrance and yard safe . Upon entrance, there is a small passage area leading to the living area of the home, adjoining to it is the dining area. Living and Dining areas are designated for Day care activities. Applicant has set up the area with all the needed activities, while other side is arranged with napping items, where Infant crib and cots would be arranged. Age appropriate activities and furniture was observed.

Older infants, Toddlers and Preschool age children shall nap on cots, linens and blankets shall be brought from home, washed on a weekly basis by the parents. Dining activities shall be held in the dining area. Infants shall use portable high chairs which are arranged on the floor.

Applicant provides care to Infants and has all the required Infants items , including changing mats/ portable high chair, cribs and toys were observed. All Infant items: diapers / wipes/ lotions and milk shall be provided by the parents. Mother's milk shall be labeled and stored appropriately. Per Applicant infants shall not be left unattended while they are sleeping. (2)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC809 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MENDIS, APPUWAHANDI & CHRISTOFELSZ, SURESH	FACILITY NUMBER: 304314040
	VISIT DATE: 07/26/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA discussed the Safe Sleep practice with Applicant Ms. Mendis, Appuwahandi

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
LPA reviewed with applicant the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used if they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold.
Applicant shall maintain LIC 9227 form in the infant file. ( Printed and given to the applicant)

Hard copy and link of Child Care Providers Guide to Safe Sleep provided to licensee on this day: https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

The bathroom is located in the passage area, adjoining the bedrooms , it is a full bathroom, with small step stool and toddler toilet seat for the younger toddlers. There is a cabinet under the sink with child safety locks installed. The children's bathroom was observed to be safe and free of hazardous items.

Applicant shall provide Breakfast, AM/PM snacks and lunch. If any food is brought from home and these containers shall be labelled with their names by the parents and stored accordingly.

Upon entrance through the designated main door of the home, applicant shall receive the children here, due to pandemic parents are encouraged to follow CDC guidelines, a sanitizing station has been set up at the entrance door of the house, on a side table.

OUTDOOR PLAY AREA: Applicant shall use the open front yard area and fenced back yard for outdoor activities. Front yard is completed fenced with concrete and grass flooring and there is a metal rolling gate which shall remain locked during operating hours, while the applicant also has fenced an area in the back yard for activities and the surrounding open space shall be used as bike trails/ chalk painting and physical activities. It has age appropriate activity items for children in care. It is safe for outdoor activities (3)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC809 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MENDIS, APPUWAHANDI & CHRISTOFELSZ, SURESH	FACILITY NUMBER: 304314040
	VISIT DATE: 07/26/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

There are no pets, firearms, weapons, bodies of water in the home.

The value on the 2A10 BC fire extinguisher indicates fully charged, as indicated on service tag observed. Smoke and carbon monoxide detectors were tested and are operable. Applicant has mounted the Fire extinguisher on the side wall of the entrance door. Dual Smoke / Carbon Monoxide detector is mounted in the kitchen area and there is one carbon monoxide detector in each of the bedrooms

Applicant have completed the required Mandated Reporter Child Abuse training, Health and Safety training with Nutrition and Lead Poisoning component and Pediatric First Aid and CPR which is valid through 010/10/2022. There are first aid supplies available.

The following was discussed with the applicant: In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR certification, TB clearance along with a valid criminal record clearance associated to the facility license.
Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated. The fire extinguisher type 2A-10 BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Fire and safety drills must be performed every six months and documented for review by the Department. Children and Staff records must be maintained and updated as needed and must be available for review by the Department.

No smoking, No Johnny jumpers, No Baby walkers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

Applicant shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian (4)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC809 (FAS) - (06/04)

Page: 4 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MENDIS, APPUWAHANDI & CHRISTOFELSZ, SURESH	FACILITY NUMBER: 304314040
	VISIT DATE: 07/26/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA discussed the following items with the applicant Ms. Mendis, Appuwahandi during the Exit interview:
Criminal Record statement: Applicant Ms. Mendis, Appuwahandi was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Safe Sleep : LPA discussed the safe sleep regulations with applicant Ms. Mendis, Appuwahandi & discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the Applicant Ms. Menis, Appuwahandi 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.

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS: Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-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) 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.

Review of records to be maintained : LPA reviewed with applicant Ms. Mendis, Appuwahandi 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.

Subscribe to CCLD important information

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 platform. To receive important license- related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC809 (FAS) - (06/04)

Page: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MENDIS, APPUWAHANDI & CHRISTOFELSZ, SURESH	FACILITY NUMBER: 304314040
	VISIT DATE: 07/26/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

OTHER INFORMATION AND FORMS PROVIDED: Capacity Handout for a Small Family Child Care Home. LPA explained the age requirements for the enrolled children ensuring that when there are 8 children, at least one child is enrolled in Kindergarten or 6 years old, to be in compliance with Title 22 requirements and additional forms were given to the applicant.

LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment.

The facility at the time of Pre-licensing inspection is in compliance for a (Small Family Child Care Home) with Title 22 Regulations. License shall be issued upon Management approval.

Exit interview conducted with the Applicant Ms. Mendis Appuwahandi, this report was read to the applicant and Appeal rights were presented.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC809 (FAS) - (06/04)

Page: 6 of 6