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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364817209
Report Date: 06/23/2022
Date Signed: 06/23/2022 01:29:13 PM

Document Has Been Signed on 06/23/2022 01:29 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:WICKRAMASINGHE FAMILY CHILD CAREFACILITY NUMBER:
364817209
ADMINISTRATOR:WICKRAMASINGHE, N & SFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 883-9982
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:WICKRAMASINGHE, NIMALTIME COMPLETED:
01:38 PM
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Licensing Program Analyst (LPA), Maddox met with licensee, WICKRAMASINGHE, NIMAL today for the purpose of conducting and unannounced Annual/Random inspection. Present today were 5 day care children and licensee. The home is a single story family home which has been converted from a 3 bedroom 2 bath to a 1 bedroom and 3 bathrooms (2 bathrooms have 2 toilets and 1 sink in each). Licensee states they converted 2 bedrooms to open space for the day care (during this inspection, this open area was set up as a living room). Licensee has also converted the garage to an activity area for children where children are free to perform (sing, dance, etc.). **There are no pools, spas or any other bodies of water on the premises. All adults in the home, licensee and husband only have fingerprint clearances and exams for T.B. Licensee has a total of 6 small dogs in the home around day care children. Licensee states she only cares for children ages 3 to 6 years.

The kitchen and bathrooms were toured and inspected for proper storage of chemicals, detergents, cleaning compounds, medications and sharp pointed objects, all items were made inaccessible to children. The entire yard is fenced. All unused electrical outlets are plugged and play equipment and toys
are available.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: WICKRAMASINGHE FAMILY CHILD CARE
FACILITY NUMBER: 364817209
VISIT DATE: 06/23/2022
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 Per licensee, there are no weapons or firearms of any kind on the premises. The required fire extinguisher (2A 10BC), smoke detector, and carbon monoxide devise are in operable condition. Licensee keeps a current Roster and record of Disaster drills

All adults 18 years and older living in the home or visiting for extended periods of time should have criminal background clearances with the Department of Justice and or associations, failure to comply will result in Civil Penalty assessments.

******Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 o 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 is reminded of the requirement to report and unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC 624B.

**§1597.622 Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. – Licensee does not have a record of current immunization's
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: WICKRAMASINGHE FAMILY CHILD CARE
FACILITY NUMBER: 364817209
VISIT DATE: 06/23/2022
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§1596.8662(b) (1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided.www.mandatedreporterca.com


Exit interview conducted, a copy of this report and LIC 811 left with licensee at the conclusion of this inspection. Type B citations cited today for expired CPR and First Aid training, no record of required immunization's, and no Mandated Reporter Training.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Donna Maddox
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/23/2022 01:29 PM - It Cannot Be Edited


Created By: Donna Maddox On 06/23/2022 at 01:04 PM
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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: WICKRAMASINGHE FAMILY CHILD CARE
FACILITY NUMBER: 364817209

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by: Licensee's CPR and First Aid exp 1/2022.
Deficient Practice Statement
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Based on file review, licnensee's CPR and First Aid expired 1/2022, this poses a potential health and safety risk to children in care.
POC Due Date: 07/25/2022
Plan of Correction
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Licensee has 30 days to scheule an appointment to renew her expired CPR and First aide training. LPA suggested Licenee contact CCRC.
Type B
Section Cited
HSC
1596.8662
(b) (1)   On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child 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: Licensee does not have a current Mandated Reporter Certificate
Deficient Practice Statement
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Based file review, there is no evidence licensee has completed Mandated Reporter Training which posed a potential personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
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Licensee shall access web page provided on the 809 to complete Mandated Reporter Training.
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:Mariela Ramon
LICENSING EVALUATOR NAME:Donna Maddox
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022


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