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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310216
Report Date: 06/02/2023
Date Signed: 06/02/2023 12:10:13 PM

Document Has Been Signed on 06/02/2023 12:10 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:PALMERI, MIRNAFACILITY NUMBER:
304310216
ADMINISTRATOR:PALMERI, MIRNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 463-4544
CITY:ALISO VIEJOSTATE: CAZIP CODE:
92656
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Mirna PalmeriTIME COMPLETED:
01:00 PM
NARRATIVE
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Mrs. Bootorabi. Upon arrival, an Entrance Checklist (LIC 126) was provided to the licensee Mirna Palmeri

Census upon entry:
Infants: 0
Children Over Two: 1
Adults Working Directly with Children: 1
Other Adults: 1
The licensee was operating within the licensed capacity as specified on the license. The Facility Day care hours are 6:30 am - 5 pm Monday - Friday.

One child was observed upon entry in the family room.

Posted Requirements were reviewed upon entry with licensee. The LPA verified that the following documents were posted in a prominent, publicly accessible area; License, PUB 394 Notification of Parents’ Rights, and LIC 9148 Earthquake Preparedness. During the time of the inspection the licensee did not meet the requirements. Licensee was provided a copy of LIC 9148 to complete and post.

A facility tour was conducted with the licensee. The licensee stated the main areas of care are the family room and living room. The kitchen is accessible to the children and sharp objects are stored out of reach of children by means of locked cabinets and on top of the refrigerator. The stairs in the entry of the home were blocked off by means of a baby safe gate. The fire place in the family room is blocked off by means of a glass enclosure and is inaccessible to children in care.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PALMERI, MIRNA
FACILITY NUMBER: 304310216
VISIT DATE: 06/02/2023
NARRATIVE
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Detergents, cleaning compounds, medicines, and other items that could pose a danger if readily available to children were stored inaccessible by means of being stored in the garage or closed cabinets.
Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections.

Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. The children's bathrooms are clean and sanitary. The licensee stated she currently does not have children who nap on cots but has an infant enrolled that naps in a play yard. The licensee stated the families bring the sheets and blankets. Licensee stated that the families currently enrolled take sheets with them every day. All soiled blankets and clothing are put in a plastic bag and left by the door for parents to take home stated by the Licensee.

The licensee was given a consultation on age-appropriate toys for the ages served.

The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was maintained and free of dangerous hazards to children. A consultation was provided to the licensee for areas of the outdoor space for children.

Identify Location & Functioning of the carbon monoxide, smoke detector and fire extinguisher was viewed at 9:40 am. The licensee tested the carbon monoxide and smoke detector during today’s inspection. Both were functioning. The licensee and LPA reviewed the Fire Extinguisher and the extinguisher was marked in full.

Personnel Records:The LPA requested completed personnel records for review during today’s inspection. The following documents were reviewed in the files provided by the licensee; CPR First Aid Certification, LIC 9052, Immunization records, TB clearance and LIC 9108, and a Mandated Reporter Training Certificate. Licensee did not have a separate and complete file for herself. Licensee stated she does not have an assistant at this time. A consultation was provided for licensee to maintain a file for herself and future employees.

CPR & FIRST AID was taken on 08/31/2022 and expiration date is 08/31/2024 Mandated Reporter Training was taken on 04/04/2023

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
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Document Has Been Signed on 06/02/2023 12:10 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 06/02/2023 at 10:41 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: PALMERI, MIRNA
FACILITY NUMBER: 304310216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by means of not having records in file for the infant she is currently caring for which poses a potential health, safety or personal rights risk to persons in care. The licensee was given a consultation and a copy of a sample log for her reference. Licensee was also given other resources.
POC Due Date: 06/09/2023
Plan of Correction
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The licensee stated that starting today she will begin to log the childrens observations. The licensee will be sending the logs to the LPA via email.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviewing the licensee and record review of the children, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. The licensee was missing immunization records for 2 of 2 children enrolled in her program and was provided a website where parents can retrieve vaccination records.
POC Due Date: 06/09/2023
Plan of Correction
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The licensee is going to email the LPA immunization records. The licensee will be getting immunization records from the parents before they enroll. The licensee will review the following video for RECORD KEEPING - https://ccld.childcarevideos.org/family-child-care-providers/record-keeping-in-family-child-care/ .
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023


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Document Has Been Signed on 06/02/2023 12:10 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 06/02/2023 at 10:41 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: PALMERI, MIRNA
FACILITY NUMBER: 304310216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviewing the licensee and record review of 2 of 2 children enrolled, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. The licensee did not have completed immunization record sheets or immunization records for review for 2 of 2 children in care.
POC Due Date: 06/09/2023
Plan of Correction
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The licnesee will send the completed file to LPA via email no later than 06/09/2023 and review Record Keeping Video https://ccld.childcarevideos.org/family-child-care-providers/record-keeping-in-family-child-care/
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviewing the licensee and record review of 2 of 2 children enrolled , the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. The licensee was provided a LIC 311 D for her reference and consultation on completed files for children enrolled. Licensee was missing 1 of 2 files for children enrolled.
POC Due Date: 06/09/2023
Plan of Correction
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The licensee will beseind a complete record to LPA via email. Licensee will be reviewing Record Keeping Video and LIC 311D
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023


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Document Has Been Signed on 06/02/2023 12:10 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 06/02/2023 at 10:41 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: PALMERI, MIRNA
FACILITY NUMBER: 304310216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 observation, interviewing the licensee and record review of 2 of 2 children enrolled, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. The licensee did not have a completed file for 1 of 2 children enrolled with her. A consultation was provided and a LIC 311D.
POC Due Date: 06/09/2023
Plan of Correction
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The licensee stated she would complete the file for 1 of 2 children and email it to the LPA. Moving forward the licensee will not accept children before receiving a complete file.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviewing and record review of 1 of 1 infant , the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. The licensee was not clear on the infant safe sleep log for infants. A consultation was provided to the licensee in dept of the new safe sleep regulations. Copies of a safe sleep log was provided. LPA email Safe sleep resources to licensee as well.
POC Due Date: 06/09/2023
Plan of Correction
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Licensee will begin the safe sleep logs today and save them on child's file for review.
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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023


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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PALMERI, MIRNA
FACILITY NUMBER: 304310216
VISIT DATE: 06/02/2023
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Children’s Records Reviewed: The LPA requested completed children’s records of children enrolled. Children's records were reviewed, and there was a separate, not completed, and no current record for each child. The LPA reviewed files to verify the following documents LIC 282 Affidavit Regarding Liability Insurance, Immunization Records, LIC 700 Identification, Emergency Medical Treatment, and LIC 995A Notification of Parents’ Rights.The licensee was able to meet the requirements during today’s inspection. The licensee was missing Immunization Records for 2 of 2 children and 1 of 2 children did not have a file.

Individual Sleep Plans and Sleep Logs were requested by LPA. Licensee did not meet the requirement and was reminded that 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 maintained at the facility in the infant’s file. LPA observed and reviewed LIC 9227 Individual Infant Sleeping Plan in children’s files for 1 of 1 infants. LPA discussed Sleep Logs and provided a sample copy of one to licensee. Licensee was reminded that sleep logs must be conducted every 15 min, have observers initials, child's name and available for review. Licensee was provided a Safe Sleep Consultation.

During today’s inspection, the licensee and LPA discussed the following:

- Stay up to date with LIC 9227 and discuss with parents any new changes


- Ensure 15 min checks are conducted & logged (The initial of the person checking should be included)
- 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.
- Always place infants on their backs to sleep
- 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 if 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.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PALMERI, MIRNA
FACILITY NUMBER: 304310216
VISIT DATE: 06/02/2023
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Facility License File: The LPA asked Licensee if there are any updates to be made for LIC 279 APPLICATION FOR A FAMILY CHILD CARE HOME LICENSE, LIC 610 EMERGENCY DISASTER PLAN FOR FAMILY CHILD CARE HOMES , or LIC 999 Facility Sketch. Licensee stated there are some changes and will be mailing it to the office.

Incidental Medical Services (IMS) policy was discussed and the licensee stated she does not provide IMS currently in her FCCH. 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)

Commonly Asked Questions American Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Know the Law About The Americans with Disabilities Act and Individuals with Disabilities Education Act https://rrnetwork.org/assets/general-files/Child-Care-Law-Center-ADA_IDEA_Housing-April-2019.pdf

Background Checks :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 2 adults including the licensee and 0 minor child living in the facility. The licensee was reminded that any individuals 18 years or older must have a background check clearance. The licensee was also reminded that any children turning 18 years must obtain a background check to maintain compliance.

LPA provided Guardian Information and website info:


https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian
Video: https://ccld.childcarevideos.org/family-child-care-providers/background-check-requirements-for-caregivers/
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PALMERI, MIRNA
FACILITY NUMBER: 304310216
VISIT DATE: 06/02/2023
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CCLD website www.ccld.ca.gov was provided to licensees to access regulations, updates, and licensing forms.

The licensee was informed of the important updates available at www.ccld.ca.gov and may request to be added to an email list to receive Community Care Licensing Important Notifications from the above website and selecting Receive Important Updates: https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/child-care

Technical Assistance and Advocacy Bureau

The Community Care Licensing Division, Technical Assistance and Advocacy Bureau will host a webinar via phone or ZOOM to inform providers about the no-cost services offered by the Technical Support Program (TSP).

Webinar Date and Time Tuesday, June 6, 2023, 6:00 p.m.

Register in advance for this webinar: Zoom Registration Link After registering, you will receive a confirmation email containing information about joining the webinar. Tip: Save the link to your Outlook calendar for easy access to the webinar.https://us02web.zoom.us/webinar/register/WN_fJWLW7U8Q-StwMIlUxMjaA

The licensee understands they must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care for 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.


The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed, and cited at the time of the visit.
The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: CCR 102425(j)(1), CCR 102418(a), CCR 102421(a), CCR 102421(b), CCR 102417(g)(7), CCR 102425(j)(2)(D)
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
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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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PALMERI, MIRNA
FACILITY NUMBER: 304310216
VISIT DATE: 06/02/2023
NARRATIVE
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An exit interview was conducted with the licensee. Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First-level appeals should be sent to the regional manager at the address listed above. 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.

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/inspection-process
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
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