304314232-9-22-2023-06-CC-KNAR-CVWVDJ-20230922162048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304314232
Report Date: 09/22/2023
Date Signed: 09/22/2023 04:21:07 PM

Document Has Been Signed on 09/22/2023 04:21 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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	NANAYAKKARA, PRABATH		FACILITY NUMBER:	304314232
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	09/22/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Prabath Nanayakkara		TIME COMPLETED:	04:30 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	Page 1 On 9/22/2023, Licensing Program Analyst (LPA) Karen Navar conducted an announced, in-person Pre-Licensing inspection for a new Small Family Child Care home. The LPA met with applicant Prabath Nanyakkara, who provided a tour of the home. A review of the Facility Personnel Report Summary indicates 3 adults live in the home. The adult residents received caregiver background check clearances or exemptions as required by the Department. Per the applicant, there are no minor children living in the home. The applicant is requesting a Small Family Childcare Home license. Per the applicant, operation hours will be Monday through Sunday 24-hour care and supervision will be provided to children ages 0weeks to 12years old. For the purposes of licensing, an infant is defined as any child 0 to 24 months of age. All areas on the Facility Sketch LIC999 were inspected, including but not limited to, off-limits areas. The facility is a single story home with 3 bedrooms,2 bathrooms, One bathroom is located in the hallway and one bathroom is located in the master bedroom, a living room, a den, kitchen, front yard partially fenced, and a backyard (fenced). Based on the Facility Sketch LIC999 submitted, areas off-limits to children and parents are as follows: Applicant has designated and identified the kitchen, front yard, garage, and 3 bedrooms, as the off-limits areas. The first bedroom in the hallway is made inaccessible by a child safety doorknob. The other 2 bedrooms are made in accessible to children by the means of a child-proof safety gate in the middle of the hallway to ensure inaccessibility to children in care. The kitchen is made inaccessible to children by the means of a child safety gate that is located at the entry. Inside the kitchen there is a door that leads to the garage. The door is made inaccessible to children with a latch that is about 5 feet 10 inches high. There is also a pantry/closet that has medication and knives that has been made inaccessible to children by a latch Continue Page 2

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: NANAYAKKARA, PRABATH	FACILITY NUMBER: 304314232
	VISIT DATE: 09/22/2023

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that is about 5 feet 10 inches high with a child proof safety doorknob. The lower drawers and cabinets have child proof locks to make them inaccessible to children. In the entry way there is a door that leads to the kitchen that has a child safety doorknob to make it inaccessible to children

The applicant understands that licensing staff may have access to off-limits areas during inspection visits if necessary.

Areas Designated for Day Care Activities: The applicant has designated the living room, den, hallway bathroom and back yard as the day care areas for children.

These areas that will be used by children were inspected for safety, comfort, cleanliness, ventilation, and heating. The children’s bathroom was observed to be safe and free of hazardous items with a step stool. The designated childcare areas were observed to have age-appropriate toys and educational items. A cell phone will always remain on the facility during operation hours.

Detergents, cleaning compounds, medicines, sharp objects, and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The applicant stated that there are no poisons and LPA did not observe any. Applicant stated that there are cleaning products in the garage LPA observed door leading to garage to be locked by a latch. The applicant was advised that any poisons must be locked with a key or combination lock. The applicant stated that there are no weapons or firearms on the premises. The LPA informed the applicant that when firearms are present, they must be locked and stored separately from the ammunition per CCR 102417(g)(4)(C).

The pressure gauge on the 2A-10BC fire extinguisher(s) indicates fully charged and is located at the beginning of the hallway on the wall. There are 7 wired smoke/carbon monoxide combination detectors that were tested and are operable. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
OUTDOOR PLAY AREA: Outdoor play activities will be conducted in the backyard. The backyard is appropriately fenced. LPA observed age-appropriate play equipment to be free from hazards. There are two
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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: NANAYAKKARA, PRABATH	FACILITY NUMBER: 304314232
	VISIT DATE: 09/22/2023

NARRATIVE

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sliding glass doors in the den on the left and right side that leads to the back yard. When facing the back or the house and exiting out the sliding glass door to the left there is a black wired gate that is 11 feet 6 inches long and 3 feet 6 inches tall. A second gate is behind it that is a circular shape that has three licensed dogs. The sliding glass door to the right when looking at back of house leads to a grass area with child safe toys. There are no pools.

The applicant stated he will provide food for the children through the Chicano Food Program if children have allergies, they will bring food from home. The applicant was informed that if children bring food from home, the children’s names must be labeled on their lunch bags and refrigerated/stored properly.

Per the applicant, children will nap in the living room on mats and school age will be in the den. Applicant stated that they will provide sheets and blankets and wash once a week, or the parents can. The applicant will be providing care for infants, LPA explained the infant safe sleep regulations with Prabath Nanayakkara.

A records review indicates the applicant completed the required Health and Safety Training with Nutrition and Lead Poisoning components. The applicant has a current (EMSA approved) Pediatric First Aid and Pediatric CPR certification that expires on 6/1/2025. A first aid kit and earthquake emergency backpack.

Per the applicant, there are no dual licenses at this address. The applicant’s email address was obtained during this inspection. The applicant was advised that the email address may be public information

Only during Covid-19 outbreak, the applicant will receive children at the front door. Per the applicant, upon arrival children’s temperature will be taken, their hands will be sanitized, and the children will be taken to the designated day care area by the applicant. COVID-19 guidelines and precautions were discussed with the applicant.

In the absence of the licensee, a qualified adult must be present to supervise the children—a qualified adult is an individual who has a valid and current Pediatric First Aid and Pediatric CPR certification, TB clearance and immunization, and valid criminal record clearance that is associated with the licensed facility.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: NANAYAKKARA, PRABATH	FACILITY NUMBER: 304314232
	VISIT DATE: 09/22/2023

NARRATIVE

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Annual fees must be paid by the due date, or a late fee shall be assessed and/or the License may be terminated.

The Child Advocacy Program was discussed with the applicant. The applicant was advised to register for the program to receive quarterly reports and other information in a timely manner. To register email ChildCareAdvocatesProgram@dss.ca.gov.

Reporting Requirements:

1. Changes should be reported to the Department as soon as they occur, such as construction, remodeling, telephone number changes, and/or moving out from your home.

2. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

Each family childcare home must conduct fire drills and disaster drills at least once every six months. The licensee must document the date and time of each drill. This documentation must be kept at the facility for review by the Department.

No smoking, No Johnny jumpers, No saucer chairs: any other items that fall into that category are prohibited in the facility.

Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection authority, which includes but is not limited to the right to enter the home.
when children are being cared for, interview children and adults, and review documentation.

Licensees must post each facility license number in all advertisements, publications, or announcements with the intent to attract clients.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: NANAYAKKARA, PRABATH	FACILITY NUMBER: 304314232
	VISIT DATE: 09/22/2023

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H&S 1597.622: Commencing September 1, 2016, 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. The applicant has submitted proof of immunizations.

Health and Safety Code 1596.7995: Beginning January 1, 2018, all licensed providers, applicants, directors, and employees must complete training as specified on mandated reporter duties. Training is available at www.mandatedreporterca.com. The applicant has completed the required mandated reporter training. Recertification is required every two years.

The LPA advised the applicant(s) on how to access forms, regulations, and quarterly updates on the Child Care Licensing website at: www.cdss.ca.gov/inforesources/community-care-licensing. LPA reviewed and issued the LIC311D “Forms/Records to Keep in Your Family Child Care Home” and provided the forms below.

Note: Children and Staff records must be kept and updated as necessary and must be available for review by the Department.

CHILDREN FORMS/RECORDS - Children’s files must contain the following completed documents and information:
Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Affidavit Regarding Liability Insurance (LIC 282), Parent Notification Additional Children in Care (LIC 9150), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), California School Immunization Record (CDPH 286), Individual Infant Sleeping Plan (LIC 9227), Risk and Effects of Lead Poisoning (PUB 515), Family Child Care Consumer Awareness Information (LIC 9212), Blood Glucose Testing Consent/Verification (LIC 9222), Nebulizer Care Consent/Verification (LIC 9166), Acknowledgment of Receipt of Licensing Reports (LIC 9224).
FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Unusual Incident/Injury Report (LIC 624B), Child Care Facility Roster (LIC 9040), Property Owner/Landlord Notification (LIC 9149), Property Owner/Landlord Consent (LIC 9149), Entrance Checklist – Family Child Care Homes (LIC 126), Forms/Records to Keep In Your Family Child Care Home (LIC 311D), Safe Sleep Flyer-What Does A Safe Sleep Environment Look Like?, Never Ever Shake A Baby Brochure.
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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: NANAYAKKARA, PRABATH	FACILITY NUMBER: 304314232
	VISIT DATE: 09/22/2023

NARRATIVE

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STAFF FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records as specified in Title 22 Regulations 102416.1, Notice of Employee Rights (LIC 9052), one Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108) per provider, Copy of Pediatric Cardiopulmonary Resuscitation & Pediatric First Aid (CPR & First Aid Certification), Proof of pertussis, measles, and Tuberculosis (TB) vaccines, Proof of influenza vaccine (or documentation of exemption), Proof of Mandated Reporter Training certificate, Copy of Criminal Background Clearance Transfer Request (LIC 9182), Copy of Criminal Record
Exemption Transfer Request (LCI 9188).

INFORMATION TO BE POSTED IN YOU FAMILY CHILD CARE HOME – You are required by law to post the following:
Facility License (LIC 203), Waivers (if applicable), Notification of Parent’s Rights Poster (PUB 394), Earthquake Preparedness Checklist (LIC 9148), Emergency Disaster Plan (LIC 610A) California Car Seat Law (PUB 269). ). A Notice of Site Visit (LIC 9213) must be posted for 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

OTHER INFORMATION AND FORMS PROVIDED: (Posters were emailed to the Licensee)
Capacity Handouts for a Small Family Child Care Home and Large Family Child Care Home were provided.

The following was discussed with the applicant:

Criminal Record Clearance

Prabath Nanayakkara was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated. Continue Pg.7

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: NANAYAKKARA, PRABATH	FACILITY NUMBER: 304314232
	VISIT DATE: 09/22/2023

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Landlord Consent

Applicants two daughters own the home and applicant has property control.

Incidental Medical Services Plan (IMS

APPLICANT KNOWS PROSPECTIVE CLIENTS WILL NEED IMS:

This facility does not plan to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan of Operation that includes 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) or (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, licensee, or facility representative] 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. Entrance Checklist was provided to the applicant.

Safe Sleep

LPA discussed the safe sleep regulations with the applicant 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 the applicant 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.

Megan’s Law

On this date, 08/2023, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No Continue Pg. 8

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: NANAYAKKARA, PRABATH	FACILITY NUMBER: 304314232
	VISIT DATE: 09/22/2023

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registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ

MyChildCarePlan.org

Applicant, was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Exit Interview

Exit interview conducted and report was reviewed with the [applicant, licensee, or facility representative]. Please include their name. Subscribe to CCLD important information - Child Care Centers and Family Child Care Homes:
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 platforms.
To receive important licensed 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 to receive email communication. The

Small Family Child Care Home was in compliance with Title 22 Regulations at the time of inspection. In the event additional requirements are needed, the applicant will be notified.

Once licensed, the applicant is required to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years.

In the event additional requirements are needed, the applicant will be notified. A license will be issued once all requirements are met.
Appeal rights were provided. Exit interview conducted and report was reviewed with the Prabath Nanyakkara.
End of Report

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

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