304314661-3-5-2026-06-CC-PDUN-DRVUK2-20260305143824

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304314661
Report Date: 03/05/2026
Date Signed: 03/05/2026 02:38:52 PM

Document Has Been Signed on 03/05/2026 02:38 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:	RUBASINGHE, HALSI		FACILITY NUMBER:	304314661
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 4	CENSUS: 1	DATE:	03/05/2026
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Halsi Rubasinghe		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

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) Duron conducted a case management inspection, in response to licensee’s request for a capacity increase. LPA met with licensee Halsi Rubasinghe who guided analyst on a tour of the facility. Census was taken. 1 preschool age child was present. Licensee stated there is currently three adults living in the home. Licensee stated she is not currently registered with any Foster Care agency or holds a foster parent license. Licensee was reminded if changes are made to notify the licensing office. Facility Day care hours are 7:00 AM - 6:00 PM, Monday through Friday. 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. All areas on the Facility Sketch LIC999 were inspected, including but not limited to, off-limits areas. The facility is located on two levels with 3 bedrooms, 2.5 bathrooms, a living room, a dining room, a kitchen, patio and a laundry room outside by patio. LPA observed installed safety latch on door leading to the kitchen and at the bottom of staircase to make it inaccessible to children in care. There is a fireplace located in facility. Fireplace has installed glass door and child safety latch to make fireplace inaccessible to children in care. The licensee acknowledged the children may never enter the off-limit areas during operation hours. The licensee has a cell phone that is used for childcare. The licensee was informed if a cell phone is used for childcare, it must remain on the premises at all times during hours of operation. The licensee was informed and understands the home is to be free from smoking during hours of operation. Page 1 of 5

NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Patricia Duron
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

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

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)

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

FACILITY NAME: RUBASINGHE, HALSI	FACILITY NUMBER: 304314661
	VISIT DATE: 03/05/2026

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

Areas Designated for Day Care Activities: The licensee has designated the family room (childcare room) backyard and bathroom by childcare area to be used for childcare. Children will be napping in family room (childcare room).

Garage will not be used for day care.

Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation, and heating. The children’s bathroom was observed to be safe and free of hazardous items. There are child proof locks on the cabinets and drawers under the sink in the children's bathroom. The designated childcare areas were observed to have age-appropriate toys and educational items.

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 on the premises and LPA did not observe any. 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 Childcare Regulations Section 102417(g)(4)(C).

Smoke detector and carbon monoxide was tested and are operable. The fire extinguisher type 2-A:10-B:C must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed. The pressure gauge on the 2-A:10-B:C fire extinguisher indicates fully charged, as indicated on the service tag observed (on kitchen counter).

The toys are age appropriate and in good condition for the potential ages served. Baby walkers, bouncers, jumpers, and similar items will not be used for children in care. Licensee stated there are no weapons or firearms on the premises. When firearms are present, they must be locked and stored separately from the ammunition.

OUTDOOR PLAY AREA: Children will have outside play in the backyard and the backyard is appropriately fenced. There are no bodies of water on the premises.

Page 2 of 5

NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Patricia Duron
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

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

FACILITY NAME: RUBASINGHE, HALSI	FACILITY NUMBER: 304314661
	VISIT DATE: 03/05/2026

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

The licensee stated parents will provide food for the children. The licensee 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 licensee children will nap in the family room (childcare room). Children will nap on mats. The licensee understands that there shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

The licensee stated that she will provide linens and parents will provide blankets for napping. The licensee stated that parents will provide diapers, lotion, wipes, and formula for the infants. The blankets will be send home to be washed weekly and as needed for infants. Per the applicant, a changing table will be used to change diapers. LPA advised the applicant to always supervise at all times infants when changing their diapers.

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 2/3/2027 LPA reminded applicant ensure to renew (EMSA approved) Pediatric First Aid and Pediatric CPR certification before 2/3/2027.

A first aid kit is available at the facility located in the bathroom top shelf inaccessible to children.

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

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.

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

Page 3 of 5

NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Patricia Duron
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

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

FACILITY NAME: RUBASINGHE, HALSI	FACILITY NUMBER: 304314661
	VISIT DATE: 03/05/2026

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

During today's inspection, the smoke detector and carbon monoxide were operable, and the fire extinguisher was charged. Fire/disaster drill has been conducted within 6 months.

Outdoor play activities will be conducted in the backyard/patio, which is appropriately fenced. LPA observed play equipment to be safe and free of hazards. Per licensee, children will also use Green Park approximately 15 feet from facility's patio. There are trees for shade and foam cushion underneath the equipment to absorb falls. Licensee stated children will have 100 percent supervision when accessing the Green Park with licensee. There is two gated community pools located approximately 1 mile from facility. Licensee stated community pool will not be used by children in care at facility.

Per licensee, she stated parents will provide lunch and snacks for the children. The licensee was informed that if children bring food from home, the children’s names must be labeled on their lunch bags and refrigerated/stored properly.

The licensee stated that parents will provide linens and parents will provide blankets for napping. The licensee stated that parents will provide diapers, lotion, wipes, and formula for the infants. The blankets will be sent home to be washed weekly and as needed for infants. LPA advised the licensee to always supervise at all times infants when changing their diapers.

The licensee has a current roster of children in care. During this inspection, LPA reviewed five children’s records and they were in compliance.

LPA advised the licensee how to access forms, regulations and quarterly updates online at: www.ccld.ca.gov

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep 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.

Page 4 of 5

NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Patricia Duron
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

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

FACILITY NAME: RUBASINGHE, HALSI	FACILITY NUMBER: 304314661
	VISIT DATE: 03/05/2026

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

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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; 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.

Licensee was reminded that all adults 18 and over, 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 Child Care Family 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.

Fire clearance granted on 2/19/2026.

In the areas that were evaluated, no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

A new license for operating a Large Family Child Care Home shall be issued upon final approval of management and if additional information is needed, licensee shall be contacted.

Exit interview conducted and report was reviewed with the licensee Sujata Paregi 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.

During the exit interview, the Licensee Halsi Rubasinghe, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.Exit interview conducted and report was reviewed with the licensee, Halsi Rubasinghe.
Page 5 of 5. End of Report

NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Patricia Duron
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

LIC809 (FAS) - (06/04)

Page: 6 of 6