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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004821
Report Date: 10/14/2021
Date Signed: 10/14/2021 04:00:34 PM

Document Has Been Signed on 10/14/2021 04:00 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, 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:
10/14/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Avanthi AbeygoonesekeraTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Tapia-Mandujano met with Licensee, Avanthi Dilhara Abeygoonesekera for an unannounced Case Management visit. Present in the home was Licensee. Purpose of visit was explained. Licensee has requested to change Bedroom #1 to be off limits and Bedroom #3 to be use for child care.

Licensee rents a three bedroom, one bathroom single-story house with a yard (front/side/back). The hours of operation will be from Monday-Friday 8am-5pm. DAY CARE AREA: Living Room, Kitchen, Bedroom #3, Bathroom, and backyard (including deck) OFF LIMITS AREA: Bedroom #1, Bedroom #2, 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 toured the day care area and observed that day-care area is clean, and home has proper lighting and ventilation. LPA inspected Bedroom #3. Bedroom#3 was clean and spacious. LPA did not observe any harmful objects or substances.

Based on observation, LPA will approve the Bedroom#3 for child care us today, October 14th, 2021.

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: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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