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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198008581
Report Date: 09/19/2023
Date Signed: 06/19/2024 08:35:40 AM

Document Has Been Signed on 06/19/2024 08:35 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:MIKELLY FAMILY CHILD CAREFACILITY NUMBER:
198008581
ADMINISTRATOR:MIKELLY, D. & A.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 844-4685
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
09/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Alexander and Delmy Mikelly, LicenseesTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPA) Thelma Razo conducted an unannounced Required – 1 Year inspection on 9/19/2023. A COVID 19 risk assessment was conducted prior to entering the facility. LPA met with Licensees Alexander and Delmy Mikelly who guided analyst on a tour of the facility. LPA provided a copy of Entrance Checklist—Family Child Care Home (LIC126) to Licensees. Also present during this inspection was one adult who lives on the premises and staff Carmina Armenta. There were 4 children present upon arrival one of whom was an infant. Licensee Alexander states that there are currently 15 children enrolled. LPA reviewed children's roster and is current.

This is a two story home which consists of 5 bedrooms, 2 bathrooms, kitchen, dining room, living room with fireplace which was inaccessible, fenced front yard and fenced backyard. The children use the bathroom in the hallway (1st floor), living room and dining room areas. According to licensee:
Off limits: Upstairs which was inaccessible by safety gate, both bedrooms located downstairs, and back yard.

LPA observed the following required posted documentation in the main entry way of the facility: Facility License, Publication (PUB) 394 - Notification of Parent Rights
Page 1 of 4
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Thelma Razo
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MIKELLY FAMILY CHILD CARE
FACILITY NUMBER: 198008581
VISIT DATE: 09/19/2023
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and Licensing Form (LIC) 9148 - Earthquake Preparedness form. LPA reviewed facility records for LIC 9040 - Facility Roster, LIC 610 - Facility Disaster Plan.

The home was observed to be clean and orderly, with central air and heating. Licensing staff observed the smoke detector and the carbon monoxide detector to be in operable condition. Licensing staff observed the valve on the required 2A 10BC fire extinguisher indicates fully charged with service tag’s last entry of 08/10/23. Last disaster drill documented was conducted on 07/11/2023. The home maintains telephone service via land line and cell phone. There are toys and other age-appropriate material available for children. Licensee prepares breakfast, lunch, dinner and snacks. LPA observed a first aid kit in the facility. LPA observed a small bird kept in a cage located in the dining room.

Licensee states that there are no poisons stored in the home and understands that all poisons must be locked, to be made inaccessible to children. Per Licensee there are no firearms or weapons stored in the home. Licensing staff reminded licensee smoking is not allowed in the home. There were safe toys, play equipment and materials observed for children.

Child’s records were reviewed for (LIC) 282 - Affidavit Regarding Liability Insurance, Immunization's Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, and LIC 995A Notification of Parents’ Rights.



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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Thelma Razo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MIKELLY FAMILY CHILD CARE
FACILITY NUMBER: 198008581
VISIT DATE: 09/19/2023
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Licensee file was reviewed for the following: LIC 508 - Criminal Record Statement, Proof of immunization against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108 - Statement Acknowledging Requirement to Report Child Abuse. Pediatric First Aid and CPR certification on expires 09/04/25. Mandated Reporter Training has been completed and expires on 01/14/24. www.mandatedreporterca.com

LPA discussed the safe sleep regulations with licensee and 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 licensee 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.


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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Thelma Razo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MIKELLY FAMILY CHILD CARE
FACILITY NUMBER: 198008581
VISIT DATE: 09/19/2023
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H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The licensee's do have proof of immunization against influenza, pertussis, and measles.
LPA advised the licensee how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 day during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.



There’s no deficiency cited under California Title 22 Regulations during this inspection
Exit interview was conducted with Licensees. Licensees were provided a copy of their Appeal Rights (LIC 9058) and this report.
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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Thelma Razo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC809 (FAS) - (06/04)
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