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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312960
Report Date: 06/20/2022
Date Signed: 06/20/2022 11:07:54 AM

Document Has Been Signed on 06/20/2022 11:07 AM - It Cannot Be Edited

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:KODIKARA, KUSHARAFACILITY NUMBER:
304312960
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
06/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kushara Kodikara, licenseeTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Tina Nguyen conducted an onsite case management inspection due to licensee’s request to change the facility’s status from inactive to active. According to licensing records, licensee has been on inactive status since August 2020 to May 2021. LPA Nguyen and Kushara Kodikara, Licensee, toured the facility inside and outside and the floor and yard plan (LIC 999) were verified. LPA observed three children present at the facility.

A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are three living in the facility. Facility Day Care hours are 8:30 am-5:00pm, Monday through Friday.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas are made inaccessible by means of children safety gates and a lock on the office door. This is a one-story home which consists of 4 bedrooms, 2 bathrooms, kitchen, family room and living room. Per licensee the bedrooms and living room are off limit areas to the children. The children eat in the kitchen with 100 percent supervision per licensee. The children utilize the backyard for outdoor play time, it was observed to be fenced and free of hazards.
There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger were stored inaccessible to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. The home has age-appropriate toys for the ages served. LPA verified there is a working telephone service (cellular service). Licensee stated they use the backyard as outdoor play area. There are no bodies of water on the premises. Continue on next page (1 of 3)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Tina Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KODIKARA, KUSHARA
FACILITY NUMBER: 304312960
VISIT DATE: 06/20/2022
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The licensee Pediatric CPR/First Aid certification expired 06/2023. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee were reviewed and within compliance.

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. Licensee has completed the mandated reporter training on 06/14/2023.

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

The licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

Licensee was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/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. Continue on next page (2 of 3)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Tina Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KODIKARA, KUSHARA
FACILITY NUMBER: 304312960
VISIT DATE: 06/20/2022
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 LPA also informed facility representative 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.

A copy of “A Child Care Providers Guild to Safe Sleep” was provided to applicant:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
LPA reviewed with applicant the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold

In the areas that were evaluated, licensee was in compliance with California Code of Regulations, Title 22, Division 12 at the time of the visit and facility status will be changed from inactive status to active status.

An Inspection and exit interview were completed with licensee. The report was reviewed and discussed. Appeal Rights was discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.


The licensee was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00.
End of Report
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Tina Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
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