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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842842
Report Date: 01/22/2024
Date Signed: 01/22/2024 11:50:38 AM

Document Has Been Signed on 01/22/2024 11:50 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 SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:DE SILVA FAMILY CHILD CAREFACILITY NUMBER:
334842842
ADMINISTRATOR:DE SILVA, CHAMALIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 583-3077
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
01/22/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Chamali De SilvaTIME COMPLETED:
12:00 PM
NARRATIVE
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On January 22, 2024 at 09:25 AM, Licensing Program Analyst (LPA) Courtnee Peebles and Jessica Rubio arrived at the facility to conduct an annual inspection as part of a compliance review. 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 through Friday 07:00 AM to 05:00 PM

· Off-limit areas include: Entire second floor, Garage, Bedroom 1

· The facility is not operating within the licensed capacity and appropriate ratios. On arrival LPA’s observed one staff and eight children one whom is an infant and seven others who were all between the ages of 2 to 4 years of age. Licensee contacted an assistant and the assistant will arrive to help with children in care. This posed a potential health and safety risk to children in care. A citation will be issued.


· Appropriate supervision provided during this inspection

· A working telephone is present and the current number is on file

· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection. During the facility tour LPA's tested the carbon monoxide tester that did not appear to be in working order. This poses a potential health and safety risk to children in care. A citation will be issued.

· Fireplace is properly screened to prevent access by children

· All hazardous items are not stored inaccessible to children. During the facility tour LPA's observed lit candles that were accessible to children in care. LPA's also observed several plugs without safety coverings. Licensee covered all accessible plugs making them inaccessible while LPA's were present. This posed a potential health and safety risk to children in care. A citation will be issued.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Courtnee Peebles
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2024
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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Document Has Been Signed on 01/22/2024 11:50 AM - It Cannot Be Edited


Created By: Courtnee Peebles On 01/22/2024 at 10:39 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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: DE SILVA FAMILY CHILD CARE
FACILITY NUMBER: 334842842

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation During the facility tour LPA's tested the carbon monoxide tester that did not appear to be in working order, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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Licensee stated she will replace the batteries in the carbon monoxide detector and proof of working order will be provided to LPA by 02/22/2024.
Type B
Section Cited
CCR
102417(g)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation lit candles that were accessible to children in care. Licensee removed the candles like LPA's were present. LPA's also observed several plugs without safety coverings. Licensee covered all accessible plugs making them inaccessible while LPA's were present. , the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2024
Plan of Correction
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Licensee removed the candles and covered all accessible plugs while LPA's were present.
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Courtnee Peebles
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/22/2024 11:50 AM - It Cannot Be Edited


Created By: Courtnee Peebles On 01/22/2024 at 10:39 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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: DE SILVA FAMILY CHILD CARE
FACILITY NUMBER: 334842842

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review C2 did not have any documentation of sleep logs available, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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Licensee will begin doing sleep logs and proof will be provided to LPA via email by 02/22/2024.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, C2 did not have immunizations on file. the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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Licensee will obtain a copy of C2's immunization record and proof will be provided to LPA via email by 02/22/2024.
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Courtnee Peebles
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/22/2024 11:50 AM - It Cannot Be Edited


Created By: Courtnee Peebles On 01/22/2024 at 10:39 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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: DE SILVA FAMILY CHILD CARE
FACILITY NUMBER: 334842842

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, C3 did not have an LIC627 Consent to emergency medical treat authorization on file.,the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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Licensee stated the correct forms will be given to the parents dated and signed and proof will be provided to LPA via email by 02/22/2024.
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Courtnee Peebles
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/22/2024 11:50 AM - It Cannot Be Edited


Created By: Courtnee Peebles On 01/22/2024 at 11:10 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 STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: DE SILVA FAMILY CHILD CARE
FACILITY NUMBER: 334842842

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.5(e)
If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, there were eight children present total with no school age children present making the licensee out of ratio. Licensee called an assiatnt to come help and assist. Assistant arrived while LPA's were present. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2024
Plan of Correction
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While LPA's were present an assistant arrived to help the licensee with the children in care, making them in ratio.
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Courtnee Peebles
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024


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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 SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: DE SILVA FAMILY CHILD CARE
FACILITY NUMBER: 334842842
VISIT DATE: 01/22/2024
NARRATIVE
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·Weapons are not present/stored according to Title 22. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations

· Stairs are barricaded. Licensee was reminded that staircase must remain inaccessible during day care hours.

· Clean, safe and age appropriate toys

· Current roster on file.

· Facility Sketch, Emergency Disaster Plan and Notification of Parent’s Rights poster are posted

· Documentation of fire and disaster drills on file – Last drill conducted first week of December. Licensee was reminded that all fire/ disaster drills are to be conducted and documented once every six months.

· 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.

· Verification of control of property on file

· Children’s records are not complete. During record review C2 did not have any documentation of sleep logs available. This poses a potential health and safety risk to children in care. A citation will be issued. During record review C2 did not have immunizations on file. This poses a potential health and safety risk to children in care. A citation will be issued. During record review C3 did not have an LIC627 Consent to emergency medical treat authorization on file. This poses a potential health and safety risk to children in care. A citation will be issued.

· Employee’s records are complete

· Mandated Reporter Training completed on 09/28/2022

· Pediatric CPR and First Aid Card expire on 08/13/2024

· Health & Safety Certificate - completed

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Courtnee Peebles
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024
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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 SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: DE SILVA FAMILY CHILD CARE
FACILITY NUMBER: 334842842
VISIT DATE: 01/22/2024
NARRATIVE
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·Resident and/or staff records were reviewed and all adults who require caregiver background checks have received all required clearances and/or exemptions.

The licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

The Licensee was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov



The Licensee can submit transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations858@dss.ca.gov

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.

Licensee was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care 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.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Courtnee Peebles
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024
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 SOUTH EAST, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: DE SILVA FAMILY CHILD CARE
FACILITY NUMBER: 334842842
VISIT DATE: 01/22/2024
NARRATIVE
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Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.

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.

See LIC809-D for cited deficiencies

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.

An exit interview was conducted, and this report was reviewed with the licensee Chamali De Silva. Appeal rights were discussed and provided during the exit interview.



A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Courtnee Peebles
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024
LIC809 (FAS) - (06/04)
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