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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845781
Report Date: 04/17/2023
Date Signed: 04/17/2023 02:09:23 PM

Document Has Been Signed on 04/17/2023 02:09 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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:KUMARAPPERUMA FAMILY CHILD CAREFACILITY NUMBER:
334845781
ADMINISTRATOR:KUMARAPPERUMA,MARIAN SHERMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 207-2848
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 14TOTAL ENROLLED CHILDREN: 15CENSUS: 10DATE:
04/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Marian Kumarapperuma, LicenseeTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Elyse Jones arrived at the facility to conduct a Case Management inspection in response to the receipt of an Unusual Incident Report (UIR) from the facility. It documents Child # 1 reported to his/her Authorized Representative that the Licensee allegedly hit him/her in the face. Interviews were conducted. Further information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided to the licensee.

At the time of the inspection, LPA toured the facility, took census, and met with Licensee Marian Kumarapperuma. During the inspection LPA observed nine children including two infants. About 10 minutes into the inspection a school age child arrived. The Licensee stated her Assistant was not present due to being on lunch and would arrive back at the facility around 2:30PM. LPA also observed the two infants with loose blankets in their playpens while preparing for nap time.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Licensee Marian Kumarapperuma.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2023
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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Document Has Been Signed on 04/17/2023 02:09 PM - It Cannot Be Edited


Created By: Elyse Jones On 04/17/2023 at 01:22 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KUMARAPPERUMA FAMILY CHILD CARE
FACILITY NUMBER: 334845781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/18/2023
Section Cited
CCR
102416.5(e)

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Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c). This requirement was not met as evidence by:
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Licensee agrees to develop and submit a plan to the Department on how she will ensure she will be in compliance with the regulation. She will also submit one schedule with all children's days & times of attendance.
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Based on the observation and Licensee's admission, the Licensee did not meet the above regulation which poses an immediate risk to the Health, Safety & Personal Rights risk to the children in care. During the inspection LPA observed the Licensee providing care to 10 children without an Assistant.
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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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2023 02:09 PM - It Cannot Be Edited


Created By: Elyse Jones On 04/17/2023 at 01:30 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KUMARAPPERUMA FAMILY CHILD CARE
FACILITY NUMBER: 334845781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
Section Cited
CCR
102425(b)

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Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. This requirement was not met as evidenced by: Based on the observation, the Licensee did not meet the above regulation which poses a potential Health, Safety & Personal Rights risk to the children in care.
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Licensee agrees to submit a statement which states she understands the regulation.

Safe Sleep regulations were provided during inspection.
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During the inspection LPA observed two awake infants in separate playpens with blankets. The infants were preparing for naptime.
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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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023


LIC809 (FAS) - (06/04)
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