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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004821
Report Date: 07/26/2024
Date Signed: 07/26/2024 05:42:35 PM

Document Has Been Signed on 07/26/2024 05:42 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/
DIRECTOR:		ABEYGOONESEKERA, AVANTHI DFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 289-0945
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 0DATE:
07/26/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Avanthi AbeygoonesekeraTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On July 26th,2024 Licensing Program Analyst (LPA) Kassandra Medrano conducted an annual required inspection which included a tour of the home and yard, and a review of the required day-care forms with the licensee, Avanthi today. As well to add the front yard and left side yard which were previously off limits. Present in the home is Licensee, during the visit it was stated that she is closed for summer break and she will reopen 8/2/2024. There were no children in yard. OFF LIMIT AREAS: Garage, Right side yard, Bedroom 1, Bedroom 2, and Laundry room which will occasionally be used to cross into home. Adults living in the home are Licensee, and Husband, Sarada Weerasinghe. A review of records indicates that all adults working or living in the home who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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. The day-care operates 8am-5:30pm, Monday- Friday. LPA observed the following: No baby walkers, bouncers, exercausers, etc. allowed to be used during day-care hours. Home has proper lighting and ventilation. There is a fireplace in the home and it is properly barricaded. LPA spoke to licnesee about built in firepit in the yard, and licensee stated that she does not use it. Home has a working telephone, a working smoke and carbon monoxide detector, and a fully charged 2A10BC fire extinguisher. Licensee stated that there is no body of water on the property, and facility was inspected and no body of water were found. Licensee states there are no guns or weapons of any kind in the home. During review of files, Licensee’s CPR and First Aid expires on 5/2025. Emergency drills have been conducted and are current. Licensee provides daily snacks and meals. Licensee has chef on site that cooks organic meals. Isolation of sick children reviewed/discussed. During file review it was observed that files are current and required forms are found in staff and children's files. Capacity options were reviewed. Licensee understands that care cannot be provided for more than the capacity as stated on the license. Requirements for reporting suspected child abuse was discussed, as well as reporting requirements for unusual incidences.

Report continued on page 2..
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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: 07/26/2024
NARRATIVE
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All required postings are properly posted (License/Parent’s Rights poster/Emergency Disaster Plan and Earthquake Preparedness Checklist) Licensee was reminded that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and1597.662. It was found that 2 staff were missing updated flu shot or declination. Licensee was informed about the Provider Information Notices (PINs) on CCLD website. Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com). It was found during the review of files that two staff were missing current certificates. 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-andresources/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. 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. Incidental Medical Services (IMS) policy was discussed. 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/. This report and appeal rights were discussed with Licensee. This report must be available in the
facility for public review. 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.

During the exit interview, the licensee, Avanthi, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS,.Exit interview conducted and report was reviewed with the licensee, Avanthi.

California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/26/2024 05:42 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 07/26/2024 at 04:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ABEYGOONESEKERA,AVANTHI DILHARA
FACILITY NUMBER: 414004821

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in 2/4 staff were missing current certficates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2024
Plan of Correction
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Licensee to send certificates to LPA via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ali Zebila
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
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