Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312831
Report Date: 09/13/2017
Date Signed 09/13/2017 01:59:52 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:LIYANAGE, CHAMARIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 769-3494
CITY:IRVINESTATE: CAZIP CODE:
92614
CAPACITY:14CENSUS: 5DATE:
09/13/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Chamari LiyanageTIME COMPLETED:
02:30 PM
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
An inspection was conducted at the facility by LPA, Dean Valencia. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are presently 4 adults living in the home.

During today’s inspection the home and grounds were toured and the licensee was operating within the licensed capacity. There were 5 preschool age children in care. An adult assistant was assisting with care of the children. Operating hours are 6am to 6pm, Mon–Fri. The floor plan was verified. Off limits areas are made inaccessible by means of high latches. The licensee's pediatric CPR/First Aid certification is expired. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. Poisonous items are not stored on site, and none were observed during today's inspection. There is a working carbon monoxide detector, smoke detector, and fire extinguisher in the home. The licensee has a current roster of children in care. The facility has conducted an emergency drill within the past six months. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's visit. The children use the backyard as the outdoor play area, and it is completely fenced. The outdoor play area is free from hazards. There are no bodies of water on the premises. Children's records were reviewed, and in substantial compliance. Incidental Medical Services (IMS) policy was discussed. 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: http://www.ada.gov/childqanda.htm . Proof of immunization against pertussis and influenza (or written declination) for licensee(s)/assistants/volunteers within compliance of SB 792 were reviewed. Proof of immunization against measles was unable to be provided. (continued on LIC809C).
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2017
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LIYANAGE, CHAMARI
FACILITY NUMBER: 304312831
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2017
Section Cited
CCR
102416(c)
1
2
3
4
5
6
7
102416(c) Personnel Requirements. The Licensee and other personnel as specified shall complete training on preventive health practices including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
1
2
3
4
5
6
7
The licensee stated she will submit proof of completion of a pediatric CPR/First aid course, by 10/4/2017.
8
9
10
11
12
13
14
The licensee's pediatric CPR/First Aid certification has expired. This is a potential threat to the children's health and safety.
8
9
10
11
12
13
14
Type B
10/04/2017
Section Cited
HSC
1597.622
1
2
3
4
5
6
7
Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
1
2
3
4
5
6
7
The licensee stated she will submit documentation of proof of immunization against measles, by 10/4/2017.
8
9
10
11
12
13
14
The licensee did not have proof of immunization against measles available for review. This is a potential threat to the children's health and safety.
8
9
10
11
12
13
14
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: (714) 703-2808
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2017
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: 09/13/2017
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
The licensee was advised on how to receive notifications about quarterly updates, and provided with the Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov
A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative. English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

Exit interview was conducted. Report reviewed and discussed. Notice of Site Visit was posted during the visit. 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. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov. This report is to be on file and accessible for public review at the facility for at least 3 years.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. The licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2017
LIC809 (FAS) - (06/04)
Page: 2 of 3