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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336300784
Report Date: 05/29/2024
Date Signed: 05/29/2024 11:36:08 AM

Document Has Been Signed on 05/29/2024 11:36 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 SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:DASANAYAKA FAMILY CHILD CAREFACILITY NUMBER:
336300784
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 1DATE:
05/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Wasanthi DasanayakaTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA), Kelli Waters, conducted a Case Management visit to follow up on Unusual Incident Report (UIR) that was submitted to Licensing by the facility on 05/28/24. LPA met with Wasanthi Dasanayaka, Licensee, to discuss incident. LPA Waters conducted a tour of facility, interviewed Licensee and reviewed records.

During children’s file review it was noted that children’s files were incomplete. LPA found that 1 out of 5 children enrolled were missing immunization records in their files, 1 out of 5 records were missing a LIC 700 parent signature and 1 out of 5 records was missing a LIC 282. 4 out of 5 records were missing licensee information on multiple pages.

Licensee was able to produce the immunizations for 3 children while via email while LPA was present.

Licensee will be cited under California Code of Regulations and Title 22, regarding immunizations. See 809-D for cited deficiencies.

An exit interview was conducted, and a copy of this report was provided.

A copy of this report must be made available to the public, at the facility site, for 3 years.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Kelli Waters
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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 05/29/2024 11:36 AM - It Cannot Be Edited


Created By: Kelli Waters On 05/29/2024 at 11:15 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: DASANAYAKA FAMILY CHILD CARE
FACILITY NUMBER: 336300784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2024
Section Cited
CCR
102418(g)

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102418 Immunizations (g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.
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Licensee will obtain proof of immunizations and email to LPA.
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This requirement is not met as evidenced by:
Based on record review, the licensees did not comply with the section cited above as 1 out 5 children enrolled did not have proof of required immunizations which poses a potential health, safety or personal rights risk to persons in care.
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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:Carlos Martinez
LICENSING EVALUATOR NAME:Kelli Waters
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024


LIC809 (FAS) - (06/04)
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