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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313693
Report Date: 12/18/2019
Date Signed: 12/18/2019 12:07:01 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:MILETICH, FIORELLAFACILITY NUMBER:
304313693
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
12/18/2019
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Fiorella Miletich - ApplicantTIME COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Chan conducted an announced Pre-licensing inspection of the facility on today's date. The LPA toured the facility with the applicant, Fiorella Miletich. Present during today's inspection was the applicant and the applicant’s mother. Currently there are two adult residents and three minor children living in the home; no assistants. Applicant stated she is not currently not registered with any Foster Care agency or holds a foster parent license. Applicant was reminded if changes to notify the licensing office.

A review of criminal clearance records on 12/09/19 indicates adults who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The facility is a two-story home with five bedrooms, three bathrooms, living room, formal dining room, family room, dining room, kitchen, laundry room, garage, porch, and backyard that is fenced. The applicant has designated the family room, dining room, one bedroom downstairs, one bathroom downstairs, and the porch as part of her day-care. The porch and the backyard are separated by means of child proof gates. Applicant has placed the kitchen, formal dining room, living room, garage, laundry room, backyard, and all of the second story as off limits and has placed child proof gates and door handles to prevent the children from entering the off-limit areas during operation hours. The applicant acknowledged the children may never enter the off-limit areas. Control of property was verified by LPA during today’s inspection via letter of authorization from the property owner. The applicant has a landline and a cell phone that is used for child care. The applicant was informed if a cell phone is used for child care, it must remain on the premises at all times during hours of operation. Applicant was informed and understands the home is to be free from smoking during hours of operation.

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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph ChanTELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019
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: MILETICH, FIORELLA
FACILITY NUMBER: 304313693
VISIT DATE: 12/18/2019
NARRATIVE
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The facility has two fireplaces. One fireplace is in the living room, the fireplace is screen off and the living room is made inaccessible using baby proof gates. The other fireplace is in the family room which is made inaccessible by a wooden board that is permanently attached to the fireplace by means of screws. Cleaning solutions/chemicals, utensils, and sharp knives located in the kitchen are all made inaccessible by means of safety gates. Poisons/Hazardous items are not stored on site, and none were observed. There is a no body of water in the home. The toys are age appropriate and in good condition for the potential ages served. Baby walkers, bouncers, jumpers, and similar items will not be used for children in care. The applicant stated there are no weapons or firearms on the premises. When firearms are present, they must be locked and stored separately from the ammunition. During today's inspection, the smoke detector and carbon monoxide were operable, and the fire extinguisher was charged.

EMSA approved (PEDIATRIC) CPR & (PEDIATRIC) First Aid are current for the applicant and expires on 05/2021. Applicant completed the 8-hour Preventative Health Practices and Nutrition Course with Quincy Cunningham on 05/19/19.

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 following was discussed with applicant: Individuals who are 18 years of age or older living or working in the home must be fingerprint cleared prior to being present in the facility. LPA provided applicant with the website for Live-Scan locations www.oag.ca.gov/fingerprints/locations for all adults complete LIC 9163.

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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph ChanTELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019
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: MILETICH, FIORELLA
FACILITY NUMBER: 304313693
VISIT DATE: 12/18/2019
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If adult is fingerprint cleared and associated to another facility, licensee must submit a Criminal Record Transfer Request (LIC 9182) or Exemption Transfer Request form (LIC 9188). Contact Licensing Office (714)703-2800 and ask for Personnel ID# for the individual, fax Criminal Background Transfer Request form (LIC 9182 or LIC 9188) with copy of a valid identification issued by State or Federal Government and Criminal Record Statement (LIC 508) to fax # (714)703-2831 prior to hiring adult. Failure to complete the clearance process or license association for any adult resident or assistant will result in a civil penalty assessment against the license.

LPA reviewed Unusual Incident Report (UIR) form (LIC 624B)-advised to contact Licensing Officer of the Day within 24 hours and complete the UIR within seven days by faxing LIC624B to (714)703-2831. LPA advised applicant to report to licensing any unusual incident or child absence that threatens the physical or emotional health or safety of any child or any changes to hours and days of operation and for any changes to facility, including on/off limit areas and change in phone number.

LPA reviewed with applicant requirements of Disaster Preparedness drills (documented every 6 months). The LPA advised of Affidavit Regarding Liability Insurance (LIC 282) if did not purchase liability insurance and to maintain the form in the children's files, and Car Safety Seat pamphlet were discussed and provided to the applicant. Posting requirements which include but not limited to Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9141), Parents Rights (PUB 394), Notice of Site Visit (LIC 9213), and License (LIC 203). LPA reviewed with applicant the need to maintain records including but not limited to Children records and Staff/Adults records, (see LIC 311D).

Applicant was informed of Mandated Reporter Training for self and all assistants. Department web site form was given to download forms, Title 22 regulations, and trainings on-line at http://www.ccld.ca.gov. The applicant was also informed to visit the website for Quarterly Updates. The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov.

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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph ChanTELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019
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: MILETICH, FIORELLA
FACILITY NUMBER: 304313693
VISIT DATE: 12/18/2019
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LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment.

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

The applicant was given a pamphlet on Lead Exposure and was discussed with provider. Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org. The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf

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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph ChanTELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019
LIC809 (FAS) - (06/04)
Page: 4 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: MILETICH, FIORELLA
FACILITY NUMBER: 304313693
VISIT DATE: 12/18/2019
NARRATIVE
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The facility is in compliance for a SMALL Family Child Care Home with Title 22 Regulations at the time of inspection. A license will be issued after final review, in the event additional requirements are needed, the applicant will be notified.

Appeal Rights and the appeal rights process was discussed with the applicant. The applicant was informed all appeals must be in writing and received by the licensing office within 15 business days.

An exit interview was conducted where the report was reviewed with the applicant. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph ChanTELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019
LIC809 (FAS) - (06/04)
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