304314040-8-15-2024-06-CC-AFCN-D86ST7-20240815140904

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304314040
Report Date: 08/15/2024
Date Signed: 08/15/2024 02:09:14 PM

Document Has Been Signed on 08/15/2024 02:09 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	MENDIS, APPUWAHANDI		FACILITY NUMBER:	304314040
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 4	DATE:	08/15/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:10 PM
MET WITH:	Licensee Appuwahandi Mendis		TIME VISIT/ INSPECTION COMPLETED:	02:30 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	On 08/15/24 inspection was conducted at the facility by Licensing Program Analysts (LPAs) Anna Chan and Olivia Meza. The purpose of this visit is for an annual inspection and increase in capacity. At 12:10pm LPA observed licensee, Appuwahandi Mendis caring for 4 children including 1 infant. Licensee was operating within the licensed capacity as specified on license. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are 2 adults including the licensee and 1 minor child living in the facility. Facility Day care hours are 6:30am-6:00pm, Monday through Friday. During today’s inspection, LPAs and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off-limits areas are made inaccessible by means of baby gates and door knob locks. There are 3 bedrooms, 2 bathrooms, Kitchen/Dining area, Living Room, and garage. The main childcare area is the living room which is accessed through the entrance of the facility. There is an outdoor play area which can be accessed through the living room. There is no garage access inside the home and is kept locked and inaccessible to children. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. There were no poisons or other items observed which could pose a danger to children or if they were observed, they were locked or inaccessible. Licensee stated there no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections. Page 1 of 4

SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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 08/15/2024 02:09 PM - It Cannot Be Edited

Created By: Anna Francesca Chan On 08/15/2024 at 01:09 PM

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: MENDIS, APPUWAHANDI	FACILITY NUMBER: 304314040
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above, licensee stated they have not done any disaster drill this year 2024, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2024
	Plan of Correction
1 2 3 4	Licensee stated they will conduct an emergency drill this month and will provide proof to LPA via email by due date of 9/16/24

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 1 infant file is missing LIC9227, Individual Infant Sleep Plan, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2024
	Plan of Correction
1 2 3 4	Licensee stated they will have the parents fill up form LIC9227 for all infants 12 months and under and will provide a copy to LPA via email by due date of 9/16/24

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:

Martha Malane

LICENSING EVALUATOR NAME:

Anna Francesca Chan

LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MENDIS, APPUWAHANDI	FACILITY NUMBER: 304314040
	VISIT DATE: 08/15/2024

NARRATIVE

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There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory and State Fire Marshal standards. The facility has not conducted an emergency drill within the past six months.

A fire clearance was granted on 8/01/24. Fire extinguisher 2:A:10-B:C was inspected for compliance. As per fire marshal inspection, garage may not be used for daycare.

A copy of Capacity Handout for a Large Family Child Care Home was given discussed.

A license with the change in capacity for 14 children (Large Family Childcare home) may be issued after a final file review.

The home has age-appropriate toys for the ages served. LPAs verified there is a working telephone service (cellular service), licensee was reminded that childcare phone needs to remain in the childcare at all times. Licensee stated they use the backyard for outdoor play. There are no bodies of water on the premises, and none was observed during this visit.

The licensee does have a current roster of children in care. 4 Child’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700), Immunization records, Affidavit Regarding Liability Insurance (LIC282), Consent for Emergency Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995A). Licensee stated, there is 3 infants under 24 months enrolled in the childcare. 1 infant is missing LIC 9227 Individual Infant Sleeping Plan. Licensee stated there are 3 infants and 3 preschool enrolled in the facility.

The licensee’s EMSA approved Pediatric CPR/First Aid certification expires on 10/2024. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee were reviewed and within compliance.
Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years.

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SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MENDIS, APPUWAHANDI	FACILITY NUMBER: 304314040
	VISIT DATE: 08/15/2024

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

The licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

LPAs 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-and-resources/safe-sleep as an additional resource. LPAs 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.

A copy of Safe Sleep regulations PIN 20-24-CCP and brochure was provided to the licensee.

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SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MENDIS, APPUWAHANDI	FACILITY NUMBER: 304314040
	VISIT DATE: 08/15/2024

NARRATIVE

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Licensee, Appuwahandi Mendis 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.

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.

Exit interview conducted, report and deficiencies were explained and reviewed with the licensee, Appuwahandi Mendis. A notice of site visit was given and must remain posted for 30 days.

Appeal Rights was discussed. The Licensee was provided a copy of appeal rights (LIC 9058 03/22) 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.

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SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

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