Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312831
Report Date: 06/23/2015 12:00:00 AM
Date Signed 06/23/2015 11:34:58 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:LIYANAGE, CHAMARIFACILITY NUMBER:
304312831
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
06/23/2015
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Chamari Liyanage TIME COMPLETED:
11:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Pre-licensing visit was made by LPA Connolly on this date due to a relocation change. Present was licensee and licensee's husband Weerakkody Gunawardena. There were no children in care. LPA toured the facility and reviewed paperwork.

A review of staff records on 06/15/2015 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances.

LPA informed the licensee that a final review of the file will be done before the license is issued. The licensee will be notified if any corrections or additions still need to be completed. Exit interview and appeal rights were explained. All appeals must be in writing and received by the licensing office within 10 days.

Web site addresses http://www.ccld.ca.gov and http://www.dss.cahwnet.gov were given to down load forms and Title 22 regulations. AB 633 fact sheet was given to the facility representative this date.

Home is one story detached. Licensee has designated the following areas of the home for the care and supervision of children: living room, kitchen, dining area, family room, hallway bathroom, master bedroom and master bathroom. The master bedroom is redesigned as a napping room. Latches in place in the bathrooms appear in good working order. Latches in place in the kitchen and dining area appear in good working order. Toys that appear age appropriate for ages served are available on the premises. There are two fire extinguishers both are too small. Licensee demonstrated that the smoke detector is in good working order.
CONTINUED ON PAGE TWO
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (703) 703-2800
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2015
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: LIYANAGE, CHAMARI
FACILITY NUMBER: 304312831
VISIT DATE: 06/23/2015
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
PAGE TWO
The backyard designated for outdoor play by children in care is fenced. Licensee said that when children in care are playing in the fenced backyard 100% visual supervision is provided. Some outside toys are located here.

There are no bodies of water, no pets and licensee denies firearms on the premises. Licensee also denied the use of the garage for day care purposes.

The following was observed and needs correction before a license can be issued:
1.) TB screening needed for adult resident Dinali Weerakkodi.
2.) Copy of licensee's current pediatric CPR and First Aid cards needed.
3.) Picture of fire extinguisher noted to be 2A10 BC needed.
4.) High sprinkler heads are accessible to children in care in fenced backyard, an area designated for outdoor play by children in care. Pictures of correction needed.
5.) Side yard where loose bricks and garbage cans are stored need to be made inaccessible by children in care.
6.) Similar side yard needs to be made inaccessible to ensure level of supervision.
7.) In the fenced backyard there is an approximately five foot shelf, accessible to children in care, that can easily topple over. Licensee to secure to prevent this action. Statement needed.

Proof of corrections, such as, pictures, receipts or copies need to be submitted to licensing office before the due date of 06/30/2015. If an extension is needed, please submit a letter in writing before the due date.

THE NOTICE OF SITE VISIT WAS POSTED AND DISCUSSED AS REQUIRED BY H&S CODE SEC. 1596.817.
This report must be filed in your facility file for public review for 3 years after being posted for 30 days. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (703) 703-2800
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2015
LIC809 (FAS) - (06/04)
Page: 2 of 2