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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376101126
Report Date: 06/21/2022
Date Signed: 06/21/2022 10:13:56 AM

Document Has Been Signed on 06/21/2022 10:13 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
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:HERATH, SAMADHI FAMILY CHILD CAREFACILITY NUMBER:
376101126
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 2CENSUS: 2DATE:
06/21/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Samadhi HerathTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA), Tyra Block, conducted an announced Pre-Licensing inspection for relocation with Samadhi Herath. Present at the home was licensee's spouse and 2 children. Licensee is currently providing license-exempt care to 1 family. The single story home was toured and inspected to ensure an environment safe for the care and supervision of children. Licensee rents the home and has provided landlord notification. The fire extinguisher (3A40BC), carbon monoxide detector, and smoke detector meet requirements and are operational. All hazardous items were latched/locked and secured out of reach of children. There are no bodies of water in the home. Licensee states that there are no weapons in the home. CPR and First Aid expire on 4/2023. Lead Poisoning Prevention training was taken 5/8/22. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. Staff immunization and TB requirements were met.

Licensee will be using the following rooms for childcare: Child Care Area, 1/2 Bathroom. Off limits areas include: Kitchen, Dining Room, Living Room, Full size Bathroom, and Bedrooms #1,2,and 3. They are inaccessible through the use of doorknob covers. The garage will also be off limits and is kept inaccessible through the use of a door lock. The applicant has toys and equipment available for children’s use. The home has a fenced backyard available for outdoor activities. Licensee was advised no changes should be made to the home without prior notice and/or approval from Licensing.

Licensee was reminded of requirements for children’s records, child abuse, and unusual incident reporting, immunizations, adults living or working in the home and associated civil penalties, licensee was also reminded that corporal punishment, smoking, walkers, exersaucers, bouncy seats and jumpers are not allowed in day care. All equipment that is used should be used only as intended by the manufacturer. LPA provided information regarding Safe Sleep Regulations/SIDS and Shaken Baby Syndrome. LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Tyra Block
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: HERATH, SAMADHI FAMILY CHILD CARE
FACILITY NUMBER: 376101126
VISIT DATE: 06/21/2022
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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.
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 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.
Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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. Any minor residing in the home must obtain a background check within 30 days of his/ her 18th birthday.
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.
Licensee is advised to regularly visit the Community Care Licensing WEB SITE: http://www.ccld.ca.gov/ for forms and updated regulation information. Duty Line was provided: (619) 767-2248. Southern California Child Care Advocate information was provided: (714) 703-2800 or childcareadvocatesprogram@dss.ca.gov.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Tyra Block
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: HERATH, SAMADHI FAMILY CHILD CARE
FACILITY NUMBER: 376101126
VISIT DATE: 06/21/2022
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Reminder: maximum capacity for a small family child care home: 4 infants only (infants mean any children under 24 months); or 6 children with no more than 3 infants; or (with landlord consent) 8 children with no more than 2 infants, 1 child in kindergarten or elementary school and 1 child at least age 6 including children under age 10 who live in the licensee's home.

Exit interview conducted and report was reviewed with the licensee, Samadhi Herath.

No corrections are needed; a license for 8 children will be issued effective today.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Tyra Block
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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