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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314164
Report Date: 05/31/2023
Date Signed: 05/31/2023 03:40:39 PM

Document Has Been Signed on 05/31/2023 03:40 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:BANDARA, NADEEFACILITY NUMBER:
304314164
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/31/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Nadee Bandara, ApplicantTIME COMPLETED:
03:40 PM
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A follow-up pre-licensing inspection conducted on this day by LPA Torrence. The following correction was observed:

1. The applicant turned the fishpond into a flower garden by filling it up with mulch and decorative rocks.

LPA Torrence obtained pictures of the fishpond.

The applicant is pending the Health and Safety with Nutrition and Lead Poisoning Training and an adult living in the home need immunization. Therefore, a provisional license for 90 days will be issued, which will expire on 08/23/2023.

Exit interview conducted with applicant and a copy of this report was provided to applicant.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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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