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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618736
Report Date: 10/17/2023
Date Signed: 10/17/2023 09:44:25 AM

Document Has Been Signed on 10/17/2023 09:44 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MILHOLM, JILL MARIEFACILITY NUMBER:
343618736
ADMINISTRATOR:MILHOLM, JILL MARIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 698-7460
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jill Marie MilholmTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christopher Bello arrived at the facility at approximately 8:30am and met with licensee Jill Marie Milholm for an unannounced random annual inspection and toured areas of the home accessible to children in care. The off-limits areas in the home: Master Bathroom, garage and children’s room. Off-limits areas will remain inaccessible to children by closed doors and/or supervision. The census included three children. Also present was licensee’s husband. Licensee stated there are no new residents in the home since licensure. All Adult residents have criminal record clearances.
Licensee 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.

LPA observed current CPR/First Aid certificate. LPA discussed recent changes in licensing requirements, including the posting of licensing inspection notices and reports and Parent Notification Requirements. LPA reviewed some children’s files. LPA observed fire drills were conducted at least once every six months and documented. LPA did not observe Infant Sleep log on file at time of inspection. This is considered as a potential risk to the children in care.
LPA discussed the safe sleep regulations with licensee [or facility representative] 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 informed licensee [facility representative] 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.

REPORT CONTINUES ON NEXT PAGE.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Christopher Bello
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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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Document Has Been Signed on 10/17/2023 09:44 AM - It Cannot Be Edited


Created By: Christopher Bello On 10/17/2023 at 09:30 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MILHOLM, JILL MARIE
FACILITY NUMBER: 343618736

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee will complete Safe Sleep Logs for infant in care by POC date 11/3/2023. LPA will return to clear the deficiency.
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:Amanda Blesi
LICENSING EVALUATOR NAME:Christopher Bello
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MILHOLM, JILL MARIE
FACILITY NUMBER: 343618736
VISIT DATE: 10/17/2023
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LPA observed that there were no hazardous items accessible to children. LPA observed Fireplace which was screened. LPA observed that cleaning materials were inaccessible. Fire extinguisher, smoke detector and carbon monoxide detector meet regulation. Toys appear to be safe. The backyard is fenced and gated.

Licensee stated there are no weapons in the home.
LPA observed current Mandated Reporter Training in file.

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.

LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA advised licensee of their responsibility to stay current regarding new regulations.
LPA advised licensee to sign up for the quarterly updates provided by the Childcare Advocates Program. LPA provided the link https://www.cdss.ca.gov/inforesources/Community-Care-Licensing/subscribe for the licensee to sign up for the updates.
Licensee [or facility representative] was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
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.

In the areas that were evaluated, deficiency was observed at the time of the visit and cited on LIC 809D. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee [or facility representative] Jill Marie Milholm.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Christopher Bello
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC809 (FAS) - (06/04)
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