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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414609
Report Date: 06/27/2024
Date Signed: 06/27/2024 12:13:50 PM

Document Has Been Signed on 06/27/2024 12:13 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:METOVIC, KIMETA & ADZIJAFACILITY NUMBER:
434414609
ADMINISTRATOR/
DIRECTOR:		KIMETA & ADZIJAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 355-3687
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
06/27/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:58 AM
MET WITH:Kimeta MetovicTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
NARRATIVE
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On June 27, 2024 at 8:58 AM, Licensing Program Analyst (LPA), Marilou Monico, conducted an unannounced Annual Random inspection. LPA met with Licensee, Kimeta Metovic, and explained to her the nature of today's visit. Also present in the home were Licensee, Adzija Metovic, and four (4) preschool age children. Two additional children: one infant and one preschool age arrived during the inspection. All required posting materials were posted. The daycare is open Monday thru Friday from 7:00 AM to 6:00 PM. There are no active waivers or exceptions for this facility. The daycare is a one storey home with three (3) bedrooms and one (1) bath. Per Licensee, the adults that reside in the home are herself and Adzija.

LPA obtained a copy of current children's roster during the inspection. Fire/disaster drill was conducted on January 2, 2024. LPA observed: functioning smoke and carbon monoxide detectors, glass covered fireplace, and barricaded wall heaters. LPA observed that the 3A40BC fire extinguisher is empty. Kimeta states that there are no weapons or firearms in the home.

Incidental Medical Services (IMS) policy was discussed with Kimeta. 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 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

Licensee, Kimeta Metovic, was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.
Continuation on next pages:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: METOVIC, KIMETA & ADZIJA
FACILITY NUMBER: 434414609
VISIT DATE: 06/27/2024
NARRATIVE
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Off limit areas inside the home: one bedroom. LPA observed that the home is clean and orderly. Cleaning products, sharp objects, and other items that are dangerous were stored inaccessible to children. LPA observed sufficient age-appropriate materials, toys, and play equipment for the children in the home. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (408) 355-3687. Off limit areas outside the home: garage, gated portion of the backyard and right side yard.

LPA reviewed six (6) children's files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Immunization Records, sleep log for children under 2 years old, and Individual Infant Sleeping Plan (LIC 9227) for children 0-12 months old. Kimeta indicated that she does not have daycare insurance. All six children (C-1 thru C-6) are missing the Affidavit Regarding Liability Insurance (LIC 282). Five children (C-1 thru C5) do not have the LIC 627 in their file. Three children (C4 thru C6) are missing the LIC 700. One child (C-3) is missing the second page of LIC 700. One child (C-4) is missing LIC 9227.

LPA reviewed an assistant (S-1) file. Both Licensees (Kimeta and Adzija) and S-1 have expired Mandated Reporter Training. Kimeta and Adzija have current Pediatric CPR/First Aid certifications with an expiration date of March 2025. LPA reminded Kimeta that Mandated Reporter Training must be renewed by all staff every 2 years.

LPA provided and 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. LPA also reminded Kimeta 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.


Continuation on next page:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: METOVIC, KIMETA & ADZIJA
FACILITY NUMBER: 434414609
VISIT DATE: 06/27/2024
NARRATIVE
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Licensee, Kimeta Metovic, was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&R's) throughout California.

As a result of today's inspection, deficiencies were cited on the following pages.

Exit interview conducted and report was reviewed with Kimeta Metovic, Licensee.

During the exit interview, the Licensee, Kimeta Metovic, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/27/2024 12:13 PM - It Cannot Be Edited


Created By: Marilou Monico On 06/27/2024 at 11:26 AM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: METOVIC, KIMETA & ADZIJA
FACILITY NUMBER: 434414609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Licensees, Kimeta and Adzija, and assistant (S-1) have expired Mandated Reporter Training., This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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Kimeta stated that she will submit proof of current Mandated Reporter Training for herself, Adzija, and her assistant by 07/11/24.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, five children C-1 thru C-5 are missing the Consent for Emergency Medical Treatment (LIC 627) and three children C-4 thru C-6 are missing the Identification and Emergency Information (LIC 700) and one child (C-3) is missing the second page of the LIC 700. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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Kimeta stated that she will submit completed forms and signed forms by 07/11/24.
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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


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Document Has Been Signed on 06/27/2024 12:13 PM - It Cannot Be Edited


Created By: Marilou Monico On 06/27/2024 at 11:26 AM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: METOVIC, KIMETA & ADZIJA
FACILITY NUMBER: 434414609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 6 out of 6 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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Kimeta states she will submit completed Affidavit Regarding Liability Insurance form for the six children by 07/11/24.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, C-4 is missing LIC 9227 in the file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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Kimeta states she will send completed LIC 9227 for C-4 by 07/11/24.
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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


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Document Has Been Signed on 06/27/2024 12:13 PM - It Cannot Be Edited


Created By: Marilou Monico On 06/27/2024 at 11:43 AM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: METOVIC, KIMETA & ADZIJA
FACILITY NUMBER: 434414609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of a Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to:
(1) Fireplaces and open-face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the 3A40BC fire extinguisher is empty. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Kimeta states she will purchase a required size fire extinguisher and will submit proof of purchase and photo showing that it's mounted between 3 to 5 feet above the floor.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


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