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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004821
Report Date: 11/17/2023
Date Signed: 11/17/2023 04:52:52 PM

Document Has Been Signed on 11/17/2023 04:52 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ABEYGOONESEKERA,AVANTHI DILHARAFACILITY NUMBER:
414004821
ADMINISTRATOR:ABEYGOONESEKERA, AVANTHI DFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 289-0945
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 12DATE:
11/17/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Licensee, Avanthi Dilhara AbeygoonsekeraTIME COMPLETED:
05:15 PM
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On November 17th, 2023, at approximately 2:15pm, Licensing Program Analyst (LPAs) Leslit Tapia-Mandujano and Janet Gil arrived at the facility to conduct an annual inspection. LPA was granted entrance by teacher Nicole. LPA explained the purpose of the inspection. LPAs met with licensee, Avanthi Dilhara Abeygoonsekera. Present in the facility were licensee and three assistants supervising 12 children (4 infant and 8 preschool age children). Facility is operating within capacity limits on this day. All adult living and working in the home are fingerprint cleared and associated.

Licensee rents a three bedroom, one bathroom single-story house with a yard. Licensee lives with adult partner. The hours of operation are from Monday-Friday 8:30am-5:30pm. 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.

LPAs toured day care areas of home with Licensee to inspect for health and safety hazards. LPAs 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 no pets in the home. 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. Infant children sleep in a pack and play and or child size mats. Infant children sleep in Bedroom #3 and an assistant is present at all times.

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. LPAs reviewed five children's' record. LPAs also reviewed facility and assistant records. Licensees CPR & First Aid Certificate will expire 05/2025. Licensee's Mandated Reporter Training has expired. Technical Violation was left. Last Emergency drill was conducted 06/2023. Emergency drills must be conducted at least once every six months and should be properly logged.


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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ABEYGOONESEKERA,AVANTHI DILHARA
FACILITY NUMBER: 414004821
VISIT DATE: 11/17/2023
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process

Licensee was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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.

Incidental Medical Services (IMS) policy was discussed. Licensee does not offer IMS at this time. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the licensee, Avanthi Dilhara Abeygoonsekera, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS on 11/17/23.

No deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1.

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

Exit interview conducted and report was reviewed with licensee, Avanthi Dilhara Abeygoonsekera.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
LIC809 (FAS) - (06/04)
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