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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842357
Report Date: 10/17/2024
Date Signed: 10/17/2024 11:52:39 AM

Document Has Been Signed on 10/17/2024 11:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:AMARATUNGA FAMILY CHILD CAREFACILITY NUMBER:
334842357
ADMINISTRATOR/
DIRECTOR:		AMARATUNGA, RALPH/JUNEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 614-4345
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
10/17/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:37 AM
MET WITH:Ralph Amaratunga, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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On date and time listed, Licensing Program Analyst (LPA) Elyse Jones arrived at the facility to conduct an annual inspection. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:
Normal days and hours of operation are: Monday-Friday 6:30AM-6:00PM

OFF-LIMIT AREAS INCLUDE: All of upstairs, all of downstairs, Laundry Room ,Garage

The facility is operating within the licensed capacity and appropriate ratios


· Fire Clearance granted 4-20-2017
· Appropriate supervision provided during this inspection
· A working telephone is present and current number on file
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.
· Fireplace is properly screened to prevent access by children in an off limits area
· All hazardous items are stored inaccessible to children
· Toxins are locked
· Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· Stairs are barricaded in off limit area
· Verification of control of property on file
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Mandated Reporter Training expires on S1 9-29-2026
· Pediatric CPR and First Aid Card expires on S1 9-2026
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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 10
Document Has Been Signed on 10/17/2024 11:52 AM - It Cannot Be Edited


Created By: Elyse Jones On 10/17/2024 at 10:26 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: AMARATUNGA FAMILY CHILD CARE
FACILITY NUMBER: 334842357

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370
102370 Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 102370(j)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observation, interview, and record review, the Licensee did not meet the above regulation which poses an immediate Health, Safety & Personal Rights risk to the children in care. LPA observed S2 providing Care & Supervision to the children in care. S2 stated he/she started working at the facility August 15, 2024. Additionally, the Licensee stated R1 is residing in the home. S2 and R1 are not associated to the facility. Proof of request to associate could not be provided.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee understands prior to employment or presence in the home all adults must have a criminal record clearance and be associated to the facility. Licensee agrees to submit required documents to the Department to have S2 and R1 associated to the facility on or before POC date on 10-18-2024. $1000 Civil Penalty assessed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: AMARATUNGA FAMILY CHILD CARE
FACILITY NUMBER: 334842357
VISIT DATE: 10/17/2024
NARRATIVE
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·Health & Safety Certificate – On file
· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Clean, safe and age appropriate toys
· Current roster on file
· Documentation of fire and disaster drills on file – Last drill conducted on 3-7-2024
· Children’s records are NOT complete
· Employee’s records are NOT complete
· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov

· Resident and/or staff records reviewed on 10-17-2024 indicate that all adults who require caregiver background checks have NOT received all required clearances or exemptions.

· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov

LPA discussed the safe sleep regulations with Ralph Amaratunga, Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed Ralph Amaratunga, Licensee 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.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: AMARATUNGA FAMILY CHILD CARE
FACILITY NUMBER: 334842357
VISIT DATE: 10/17/2024
NARRATIVE
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Ralph Amaratunga, 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.

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/.

Ralph Amaratunga, Licensee was reminded that all adults 18 and over living or working in the home, 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.

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 platform. 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.

Ralph Amaratunga, 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.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: AMARATUNGA FAMILY CHILD CARE
FACILITY NUMBER: 334842357
VISIT DATE: 10/17/2024
NARRATIVE
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The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

If a Civil Penalty has been assessed during this inspection. Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH.

See LIC809-D for cited deficiencies.

LPA informed Licensee, that this report dated 10-17-2024 documents one Type A citations. Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the safety of children in care. Also, LPA informed the Licensee, to provide an Acknowledgement of Receipt of Licensing Report (LIC 9224), that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed LIC 9224 must be placed in the child's file for verification.

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

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: AMARATUNGA FAMILY CHILD CARE
FACILITY NUMBER: 334842357
VISIT DATE: 10/17/2024
NARRATIVE
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A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Ralph Amaratunga, Licensee.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 10/17/2024 11:52 AM - It Cannot Be Edited


Created By: Elyse Jones On 10/17/2024 at 10:58 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: AMARATUNGA FAMILY CHILD CARE
FACILITY NUMBER: 334842357

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

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
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Based on the record review, the Licensee did not meet the above regulation which poses a potential safety risk to the children in care. During the review of the fire drill the LPA observed the last fire drill conducted on 3-7-2024.
POC Due Date: 10/30/2024
Plan of Correction
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Licensee understands fire drills must be conducted at least once every six months. Licensee agrees to conduct a fire drill and submit documentation to the Department on or by POC due date of 10-30-2024.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses a potential safety risk to the children in care. During review of staff files the LPA was unable to review a Mandated Reporter certificate for S1.
POC Due Date: 10/30/2024
Plan of Correction
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Licensee understands all staff working with the children must have a current Mandated Reporter certificate on file. Licensee understands training must be completed every two years and can be taken at www. Mandatedreporterca. com. Licensee agrees to have S2 complete training and submit certificate of completion to the Department on or by POC due date of 10-30-2024.
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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 10/17/2024 11:52 AM - It Cannot Be Edited


Created By: Elyse Jones On 10/17/2024 at 10:58 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: AMARATUNGA FAMILY CHILD CARE
FACILITY NUMBER: 334842357

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses a potential safety risk to the children in care. During staff file review the LPA was unable a completed staff file for S1.
POC Due Date: 10/30/2024
Plan of Correction
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Licensee understands all staff must have a file available for review during inspection with required forms and information. Licensee agrees to review regulations and obtain required forms and information for S2 then submit it to the Department on or by 10-30-2024.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses a health risk to the children in care. During review of staff files the LPA was unable to review immunizations for S2. Additionally, R1 does not have a TB Clearance on file.
POC Due Date: 10/30/2024
Plan of Correction
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Licensee understands all adults working with children must have MMR/DTap and a TB Clearance on file. Licensee understands all adult residents must have a TB Clearance on file. Licensee agrees to obtain proof of immunizations and TB clearance then submit to the Department on or by POC due date on 10-30-2024.
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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 10/17/2024 11:52 AM - It Cannot Be Edited


Created By: Elyse Jones On 10/17/2024 at 10:58 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: AMARATUNGA FAMILY CHILD CARE
FACILITY NUMBER: 334842357

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on the record review, the Licensee did not meet the above regulation which poses a potential safety risk to the children in care. During the children’s file review the LPA was unable to review an LIC 627 Consent for Emergency Medical Treatment for C2 and C3.
POC Due Date: 10/30/2024
Plan of Correction
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Licensee understands all required Licensing forms must be available for review during inspections. Licensee agrees to obtain an LIC 627 for C2 and C3 then submit to the Department on or by POC due date of 10-30-2024.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on the record review, the Licensee did not meet the above regulation which poses a potential safety risk to the children in care. During the children’s file review the LPA was unable to review an LIC 700 Identification and Emergency form for C5.
POC Due Date: 10/30/2024
Plan of Correction
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Licensee understands all required Licensing forms must be available for review during inspections. Licensee agrees to obtain an LIC 700 for C5 and submit to the Department on or by POC due date of 10-30-2024.
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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 10/17/2024 11:52 AM - It Cannot Be Edited


Created By: Elyse Jones On 10/17/2024 at 10:58 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: AMARATUNGA FAMILY CHILD CARE
FACILITY NUMBER: 334842357

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review, the Licensee did not meet the above regulation which poses a potential safety risk to the children in care. During the children’s file review the LPA was unable to review an LIC 995 Parents Rights for C3.
POC Due Date: 10/30/2024
Plan of Correction
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2
3
4
Licensee understands all required Licensing forms must be available for review during inspections. Licensee agrees to obtain an LIC 995 for C3 and submit to the Department on or by POC due date of 10-30-2024.

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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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