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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004821
Report Date: 08/19/2021
Date Signed: 08/20/2021 09:08:12 AM

Document Has Been Signed on 08/20/2021 09:08 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ABEYGOONESEKERA,AVANTHI DILHARAFACILITY NUMBER:
414004821
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/19/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:AVANTHI ABEYGOONESEKERATIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Tapia-Mandujano met with Applicant, Avanthi Dilhara Abeygoonesekera for a scheduled Pre-Licensing visit. Present in the home was applicant. Purpose of visit was explained. Applicant has applied for a Small Family Child Care License.

Applicant rents a three bedroom, one bathroom single-story house with a yard (front/side/back). Applicant lives with adult husband. The hours of operation will be from Monday-Friday 8am-4:30pm. DAY CARE AREA: Living Room, Kitchen, Bedroom #1, Bathroom, and backyard (including deck) OFF LIMITS AREA: Bedroom #2, Bedroom #3 (Pass through only), Laundry Room, Garage, front and side yard. All off limit areas are properly barricaded. LPA inspected applicant’s home for health and safety hazards.

LPA observed the following: Day-care is clean, orderly with a variety of age appropriate toys for the children. All furniture inspected is in good repair. The applicant has a fully stocked First Aid kit and thermometer. The home has no bodies of water, pets. Home has a fireplace that is properly barricaded. The garbage cans have tight fitting lids. The home has age appropriate equipment available for children in care. Applicant was reminded baby walkers, bouncers, jumpers and any other similar items are to not be used for children in care. Discipline policy was discussed.

The home has sufficient lighting and ventilation. Applicant states they will conduct an emergency drill once every six months and log drills. Applicant's CPR expire on 04/2023. Mandated Reporter Training Certificate for applicant expire on 6/2023. Applicant was advised all adults, 18 years and older living in the home, helper, or assistant must have finger print clearance and must be associated to the facility prior to having any contact with children in care, failure to do so could result in an immediate civil penalty of $100.00 each day.


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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ABEYGOONESEKERA,AVANTHI DILHARA
FACILITY NUMBER: 414004821
VISIT DATE: 08/19/2021
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During the inspection the following was discussed and reviewed with applicant:
*Incidental Medical Services (IMS) policy
*Sick child and Food preparation policy
*Safe sleep handout and PIN 20-24 CCP
*Applicant was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Applicant was reminded about the Provider Information Notices (PINs) on CCLD website.
*Capacity limits of a Small License
*Reporting requirements and Covid-19 Technical Assistance

This report is discussed and explained to the applicant. Records to be Maintain in the facility was previously explained and printed copies were provided to applicant to use for all children in care. Mandatory Posting Requirements: License, Emergency Disaster Plan, and Notification of Parents Rights Poster.

Prior to licensure, applicant must complete the following:
*Provide proof of a Fire Extinguisher (2A:10BC or greater)
*Provider proof of a working Smoke Alarm
*Provide proof of a working Carbon Monoxide Alarm
*Provide proof of baby gate blocking side yard

Copy of this report was emailed to the licensee. Signed copy of this report will be kept in the facility file and made available for public review. Desk Duty is available Monday through Friday between 8:00 AM - 5:00 PM at (650) 266-8800. Website for forms and Regulations: www.cdss.ca.gov
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
LIC809 (FAS) - (06/04)
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