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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004821
Report Date: 06/30/2022
Date Signed: 06/30/2022 05:01:26 PM

Document Has Been Signed on 06/30/2022 05:01 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: 4CENSUS: 3DATE:
06/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Licensee, Avanthi Dilhara AbeygoonesekeraTIME COMPLETED:
11:00 AM
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On June 30th, 2022, approximately at 9:20am, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced required annual inspection. Purpose of the inspection was explained. LPA met with licensee, Avanthi Dilhara Abeygoonesekera. Present in the facility is licensee and assistant caring for 3 children (1 infant and 3 preschool age). All adults living and working in the home have fingerprint clearance and associated to the facility.

Licensee rents a three bedroom, one bathroom single-story house with a yard. The hours of operation are 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 toured day care areas of home with Licensee to inspect for health and safety hazards. LPA observed home to be clean and in good repair with proper temperature and ventilation. There were a variety of age appropriate toys and equipment in the home which were in good condition. Home has a fireplace that is properly barricaded. Licensee has a pet cat with up to date documentation. There are no pools, and bodies of water in the premises. All cleaning supplies, poisons and other chemicals were stored inaccessible to children. Discipline Policy was discussed.

There was a fully charged fire extinguisher, smoke alarm and carbon monoxide alarm, and a working telephone on site. Phone number listed for Licensee is current. Per Licensee, there are no weapons or firearms in the home. LPA reviewed children's' record. LPA also reviewed facility records. Licensees CPR & First Aid Certificate will expire 05/2023. Licensee's Mandated Reporter Training expires 06/2023. Last Emergency drill was conducted 06/20/2022. Emergency drills must be conducted at least once every six months and should be properly logged.

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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ABEYGOONESEKERA,AVANTHI DILHARA
FACILITY NUMBER: 414004821
VISIT DATE: 06/30/2022
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Incidental Medical Services (IMS) policy was discussed. Licensee does not offer IMS, but plans to. Licensee will submit a written plan and send to department. 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: www.ada.gov/childqanda.htm.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Licensee was reminded that all adults 18 and over living or working in the home, 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.

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.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Avanthi Dilhara Abeygoonesekera.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC809 (FAS) - (06/04)
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