304314172-5-20-2025-06-CC-DVSA-DGUQGR-20250520120957

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304314172
Report Date: 05/20/2025
Date Signed: 05/20/2025 02:09:13 PM

Document Has Been Signed on 05/20/2025 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:	KEERTHISINGHE, HARSHANI		FACILITY NUMBER:	304314172
ADMINISTRATOR/ DIRECTOR:	KEERTHISINGHE, HARSHANI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 348-5322
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90621
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 6	DATE:	05/20/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Licensee, Harshani Keerthisinghe		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

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On 5/20/2025 an Annual/Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Dianna Valdez Santana who met with licensee, Harshani Keerthisinghe and census was taken. LPA observed the licensee caring for 5 children (1 infant and 4 preschool-age children) in care, her spouse/assistant arrived approximately 20 minutes later. 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 3 adults including the licensee living in the facility and two minor children. Facility Day care hours are 6:30am-6:00pm, Monday through Friday.

During today’s inspection, LPA 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 child safety gates and locked doors. The childcare area consists of the living/dining room located as soon as you enter the home, one bedroom used for napping located on the right side of the main hallway and one bathroom that is located down the main hallway to left of when it ends are the children day care areas. Licensee stated the children's primary area is the living/dining room. There are working carbon monoxide, smoke detector alarm, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspection. The facility has central A/C and heat. The facility does have a fireplace with a metal cover in the living room, additionally it is covered by a shelf ensuring it is inaccessible to children. Page 1 of 4.

NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Dianna ValdezSantana
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

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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Document Has Been Signed on 05/20/2025 02:09 PM - It Cannot Be Edited

Created By: Dianna ValdezSantana On 05/20/2025 at 11:28 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: KEERTHISINGHE, HARSHANI	FACILITY NUMBER: 304314172
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 2 staff (licensee and assistant) did not have Pediatric CPR/First Aide Certification from an approved vendor which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2025
	Plan of Correction
1 2 3 4	Licensee will email LPA Pediatric CPR/First Aid certification only from: American Heart Association, American Red Cross or by approved "Emergency Medical Services Authority (EMSA)" for licensee and the assistant by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Martha Malane
NAME OF LICENSING PROGRAM MANAGER:

	Dianna ValdezSantana
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

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: KEERTHISINGHE, HARSHANI	FACILITY NUMBER: 304314172
	VISIT DATE: 05/20/2025

NARRATIVE

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The home has age-appropriate toys for the ages served. LPA verified there is a working telephone service, which is the licensee’s cellphone. Licensee stated the children use the backyard for outside play. Backyard was inspected for safety and was found to be incompliance. There were no poisons or other items observed which could pose a danger to children. There are no bodies of water on the premises.

The licensee has a current roster of children in care. Five (5) random children’s files were reviewed during today’s inspection. Children’s records were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance. LPA observed one (1) infant from 0-12 months. LPA observed and reviewed LIC 9227 Individual Infant Sleeping Plan and Infant Sleep Log in children’s files. LPA provided a review of Safe Sleep Regulations. The licensee has a current Pediatric CPR/First Aid certification that expires 03/2027 but it is not an approved vendor by the Department.

Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee and the assistant was 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. Licensee’s Mandated Reporter Training Certificate was current, it expires 7/31/2025. Assistant’s Mandated Reporter was current and in compliance, it expires 10/30/2026.

Incidental Medical Services (IMS) policy was discussed, and licensee stated she is not currently administering medication. 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

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NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Dianna ValdezSantana
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

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: KEERTHISINGHE, HARSHANI	FACILITY NUMBER: 304314172
	VISIT DATE: 05/20/2025

NARRATIVE

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The licensee understands she must be present in the facility, must ensure children in care are supervised at all times, and children are not to be left 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, immunization's, Pediatric CPR/First Aid, and mandated reporter training.

CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website.

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-and-resources/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.

English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx

NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

•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.

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NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Dianna ValdezSantana
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

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: KEERTHISINGHE, HARSHANI	FACILITY NUMBER: 304314172
	VISIT DATE: 05/20/2025

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•Keep all items, including blankets, out of the crib or play yard.

•Pacifiers may be used as long as 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.

Safe Sleep consultation provided during today's inspection. Safe sleep 15-minute log for infant present reviewed during today's consultation and LIC 9227 Individual Sleeping Plan form. LPA Valdez Santana asked Licensee if she had any questions or concerns about Infant Safe Sleep regulations 102425. A review of this regulation was provided to Licensee.

Based on LPA’s observations, interviews and record review, the following deficiency was observed licensee did not have the Pediatric CPR/First Aid certification from an approved vendor.

In the areas that were evaluated, 1 Type B deficiency was observed of the California Code of Regulations, Title 22, Division 12 and Health and Safety Code of California at the time of the visit.

Exit interview was conducted and report was reviewed with the licensee, Harshani Keerthisinghe. Appeal Rights and were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) 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.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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.

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NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Dianna ValdezSantana
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

LIC809 (FAS) - (06/04)

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