<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312960
Report Date: 10/19/2022
Date Signed: 10/19/2022 03:29:52 PM

Document Has Been Signed on 10/19/2022 03:29 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, 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:
10/19/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Licensee Ms. Kodikara, KusharaTIME COMPLETED:
03:45 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
A Case Management (Licensee initiated) inspection for a change in capacity was conducted at the facility by Licensing Program Analyst (LPA), Desai, Ketki. LPA observed licensee Ms.Kodikara, Kushara caring for 2 infants and one preschool age child between the ages of 1 year to 4 year old. Licensee has been a care provider for a Small Family child care home since April 2016 and has been a qualified school teacher with a licensed day care facility for 15 years qualifying her to be a Large Family child care provider.

Licensee was operating within the licensed capacity as specified on license. 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 3 adults including the licensee residing in the facility.

Licensee stated, she is not registered with Resource Foster Care agency nor holds a Resource foster parent license.
Per Licensee, operation hours will be Monday to Friday, 8.00 AM to 5.30 PM, care and supervision shall be provided to children ages 6 months to 12 years of age (Infants to School age).

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children.

These is a single-story home with four bedrooms, two full bathrooms, living room, family room, kitchen, dining room, attached garage, front yard (not fenced), backyard(fenced), with two side yards.

Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. The home does not have a stairway. There is an ornamental decorative fire place in the living room with lights. It has a glass covering in front. (1)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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 5
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: 10/19/2022
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
Off limit areas: Licensee has designated three bedrooms, one full bathroom, front yard, left side yard and garage, as the off-limit areas. There is a door in the living area which opens to the other side of the home with a passage leading to the bedrooms, this door has a covered door knob on it, making the other side completely inaccessible to children. The Licensee acknowledged the children may never enter the off-limit areas . During the inspection LPA observed the off limit areas were locked.

Designated Day care area: Licensee has designated one bedroom with attached full bathroom, living room, family room, kitchen, dining room, and backyard, as part of the day-care areas. The children enter through the Right Side yard white wooden door leading into the back yard and the designated family room, where the children are received by the Licensee. Family room is the designated activity room and bedroom in front of the living room is the designated napping room for infants and preschool age children. There is also a changing table in the bedroom, since infant care is provided in this room. Both the designated day care areas have age appropriate activities and furniture for the children. Living area is open and this area is used only to access the kitchen area and the bedroom area. Kitchen is open but all the cabinets have child lock stoppers installed making them inaccessible, small table with chairs and high chairs are arranged here and this area is used during dining activity.

Napping items are arranged in the bedroom , older children nap on mats, linens & blankets are provided by the parent and sent home on a weekly basis. Infants nap in the play pens or Crib and Licensee remains in the close area, the bedroom door remains open and a security camera with monitor has also been installed. Licensee maintains the 15 minute daily sleeping log for the Infants. Day care area is safe, it is well lighted with proper ventilation and air flow.

The designated children’s bathroom was observed to be safe and free of hazardous items and bathroom was clean. There is step stool for the young children along with a small toilet seat.

A copy of “A Child Care Providers Guild to Safe Sleep” was provided to Licensee: Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

(2)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 10/19/2022
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
LPA reviewed the following safe sleep best practices with Ms Kodikara, Khushara

*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

OUTDOOR PLAY AREA: Per Licensee, children use the back yard area, It is completely fenced with grass and concrete flooring, under the shaded patio area, there are age appropriate toys with climbing structures in the grass area along with other toys, bicycles, scooters etc for children in the shaded concrete area. Backyard is safe for outdoor activities. There is also fencing installed at the end, making the A/C unit, shed and the left side yard inaccessible to children and parents.

Snacks are offered by the licensee but at this time all food items are brought from home, this containers are labelled and stored in their individual bags, in a cool area in the kitchen .
LPA verified there is a working telephone service (cellular service) along with the Control of Property.

The licensee does have a current roster of children in care and the 3 records were reviewed on today's inspection, LPA reviewed the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance. The licensee holds a valid Pediatric CPR/First Aid certification is valid through June 2023 and have also completed the required Mandated Reporter Child Abuse training on 6/14/2021. Licensee also has conducted Emergency fire and earthquake drills, last drill conducted in October 2022 and log was reviewed.
The licensee understands she must be present in the facility, must ensure children in care are supervised at all times, and children are not to be left 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, immunization's, Pediatric CPR/First Aid, and mandated reporter training. (3)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: 10/19/2022
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
A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.
Fire inspection from Orange County Fire Authority Fire inspection services have granted the fire clearance.

LPA discussed the following items with the Licensee Ms. Kodikara, Kushara during the Exit interview:

Criminal Record statement: Facility Representative Ms. Kodikara, Kushara was reminded that all adults 18 and over living or working in the home, 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 licensed Family 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.

Safe Sleep : LPA discussed the safe sleep regulations with Facility Licensee Ms.Kodikara, Kushara & discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the Facility Representative Ms. Kodikara, Kushara 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.

Incidental Medical Services (IMS): Licensee will provide IMS services: This facility plans to provide Incidental Medical Services – IMS. For IMS information , see PIN 22-02-CCP. 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



Review of records to be maintained : LPA reviewed with Facility Representative the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. LIC 311D was given to the Licensee at the time of the Exit interview. (4)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 10/19/2022
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
LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

Subscribe to CCLD important information
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important license-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

The facility was complying with Title 22 Regulations at the time of inspection

LPA discussed the ratio for the Large Family Child Care home with the Licensee: Large Family Child Care Home, and with an assistant provider, may provide care for more than 12 and up to 14 children when one child is enrolled in and attending kindergarten (including transitional kindergarten) or elementary school, and another child is at least six years old, and no more than three infants are in care.


On today’s inspection each child was observed to have a safe, healthful and comfortable accommodation furnishing and equipment’s.

A license with the change in capacity for 14 children (Large Family Child care home) will be issued after final review, in the event additional requirements are needed, Licensee will be notified.


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.

A copy of this report and Appeal rights were presented to the Licensee.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5