Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312831
Report Date: 10/19/2015
Date Signed 10/19/2015 03:04:07 PM

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: 6DATE:
10/19/2015
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Chamari Liyanage TIME COMPLETED:
03:30 PM
NARRATIVE
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Case management visit made this date due to licensee applying for a large family child care home license and the fire clearance having been issued 10/06/2015.
Present this day caring for six children was licensee, licensee's husband and licensee's adult daughter. Of the six children in care only one was an infant. All children were napping during the visit.
A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances.

The home was toured and paperwork reviewed. Roster was complete. Children files were complete. Immunization documentation was reviewed. The fire extinguisher, smoke detector and carbon monoxide detector are within regulation. Licensee's pediatric CPR and First Aid cards are current until 5/31/2016. Latches in place in the bathroom designate for day care use appear in good working order. Latches in place in the kitchen appear in good working order. Toys that appear age appropriate for ages served are within the home.

The backyard designated for outdoor play by children in care is fenced. Toys and outdoor play equipment that appear age appropriate for ages served are located here. There are no pets and licensee denies firearms on the premises.

The regulations for Large FDC Home were reviewed. A copy of the Regulation Highlights was provided. Compiling employee files was reviewed. Licensee to submit copy of the roster.

CONTINUED ON PAGE TWO
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (703) 703-2800
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2015
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 3


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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2015
Section Cited
102417(g)
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Operation of a Family Child Care Home. The home shall be free from defects or conditions which might endanger a child. The cushioning material intended to be underneath and surrounding the children climber/swing set in the fenced backyard has been removed.
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Licensee said that she will not allow children in care access to the fenced backyard until the cushioning material for the climber/swing set has been replaced and she agreed to submit to the licensing office a picture of correction. Picture of correction to be in licensing office by 10/20/15.
LPA email address provided.
Type A
10/19/2015
Section Cited
102417(g)(5)
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Operation of a Family Child Care Home. All pools, spas, hot tubs, fish ponds, or similar bodies of water shall be covered or fenced as specified to be inaccessible to children. There are two small wading pools on the side yard behind fencing that is less than five
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During the visit the licensee emptied each wading pool.
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feet in height. There was a small amount of water in each wading pool. Licensee said that the children had used the wading pools in the prior week and each pool had not been completely emptied.
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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: Marian WallmeierTELEPHONE: (703) 703-2800
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2015
LIC809 (FAS) - (06/04)
Page: 3 of 3


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: 10/19/2015
NARRATIVE
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PAGE TWO
LPA was informed by licensee that at this time the facility is not providing Incidental Medical Services (IMS). LPA informed licensee that if situation changes, a plan must be submitted indicating that IMS services are being provided. The plan must be submitted to the licensing office within 30 days. The plan should describe the facility’s policies and procedures that ensure the proper safeguards are in place. Topics to be covered include but not limited to:
· Types of IMS to be provided (Blood Glucose Testing; Inhaled Medication; EPI-PEN; Glucagon; G-Tubes); ·Records and Authorizations; ·Storage; ·Staff training; ·Safety precautions; ·When to call 911 ·Reporting Requirements
Refer to Title 22 Sections 102417 and Health and Safety Code Section 1596.750 and 1507. Technical assistance can be found at http://ccld.ca.gov/PG546.htm and http://ccld.ca.gov/PG2105.htm.

The deficiencies are cited on the attached 809D.

Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. Licensee shall keep verification of receipt in each child’s file at the facility. Licensee may use Lic.9224 for this purpose.

An exit interview was conducted, appeal rights discussed and a copy given. A written appeal must be received in the CCL office within 10 days.

THE NOTICE OF SITE VISIT WAS POSTED AND MUST REMAIN POSTED FOR 30 DAYS ALONG WITH THIS POC REPORT. Failure to post will result in civil penalties of $100.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (703) 703-2800
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2015
LIC809 (FAS) - (06/04)
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