Name of Agency: Contact Person: Telephone Number: Name of Agency: Contact Person: Telephone Number: Child: Child: Child:

Child:
x
'

OTHER SOURCES INVOLVED WITH FAMILY Name of Agency: Contact Person: Telephone Number: Name of Agency: Contact Person: Telephone Number: Child Ancillary worker/unit: Ancillary worker/unit: Child: Ancillary worker/unit: Child: Ancillary worker/unit: Child: LEGAL INFORMATION Type of order/Court orders: removal/family Docket Number: : nn1 6863-09 Type of order/Court orders: order of protection/family Docket Number: : nn1 6863-09 Type of order/Court orders: Docket Number. Type of order/Court orders: Docket Number: Docket Number: Type of order/Court orders: Type of order/Court orders: Docket Number: Type of order/Court orders: Docket Number: FOSTER CARE PLACEMENT/OTHER OUT OF HOME (N-Docket, V-Docket or D-Docket) Type of Placement Placement Date Caretaker's Name Address Ancillary worker/unit: Ancillary worker/unit: Ancillary worker/unit: Ancillary worker/unit:

Chi Child's name: Winona Piscitelli ) Child's name: Chi! Child's name: Child's name: Child's name: Child's name: Child's name:
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Child's Name Winona Piscitelli

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9-23-09

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HEALTH INSURANCE INFORMATION Policy #: Family Doctor:

Phone #:

Page 2

OFFICE OF CHILDREN AND FAMILY SERVICES CHILD PROTECTIVE SERVICES INDIVIDUAL REPORT OF INVOLVEMENT CASE NAME MERGE TO CASE ID INTAKE CASE ID CALL/INTAKE STAGE ID Pal mi otti .Winona M 24157497 26381660

******* WARNING ******* CONFIDENTIAL INFORMATION AUTHORIZED PERSONNEL ONLY

587916 23763124 2281999

06/23/2006 06/23/2006 0/320 62/06

Grant, winonna Pal mi otti , wi nona M Marzocco , Wi nona RELATED:Y

F F F

04/07/1973 04/07/1973 0/717 40/93

AA WH AA

INFORMATION AS OF 09/08/2009 fINTAKE DATE'): / _. PERSON ID 02 28610737 NAME: Piscitel1i,Paul PHONE: (516)333-2672

SEX DOB I ADDRESS M 05/27/1972 318 ELLISON AVE EXT. ETHNICITY: Non-Hispanic

ST ZIP CTY NY 11590 028

CD

RACE: white

CROSS REFERENCE HISTORY INFORMATION: CASE WORKER INTAKE STAT SAFETY STAGE ID CLSD Y 23717296 23713813 23710886 23709353 23677686 CLSD N 23274150 23119887 NASSC028) PERSON MERGE INFORMATION - CLOSED PERSON DEMOGRAPHICS: PERSON ID 27437584 28536552 MERGE DATE 06/23/2006 06/23/2006 SPLIT DATE NAME pi sci tell i .Paul Unk.unk RELATED:Y CITY MANSFIELD RACE: white
ST ZIP CTY CD

21383850 NASS(028)

PERSON ID AT INTAKE STAGE 28610737 28610737 28610737 28610737 28536552 27437584 27437584

INTAKE DATE 06/28/2006 06/26/2006 06/23/2006 06/22/2006 0/220 60/06 10/17/2005

INV *DETERMINATION* TYPE DATE TYPE ROLE CPF 06/30/2006 SUS Alleged Subject CPF 06/27/2006 SUS Alleged Subject CPF Alleged Subject CPF 06/26/2006 SUS Alleged Subject CPF 07/21/2006 UNF Non-Confirmed Subject CPF 12/20/2005 IND Confi rmed Subject

RELATIONSHIP Biological Father Biological Father Biological Father Biological Father Biological Father Biological Father Parent Substitute

FAM

* JURISDICTION * PRIMARY SECONDARY NASS(028) NASS(028) NASS(028) NASS(028) NASS(028) SULL(048) SULL(048)

08/02/2005 CPF

09/07/2005 UNF

No Role

SEX M M

DOB 05/27/1972

TYPE

ETH WH XNR

RACE

POD

.ON INFORMATION AS OF 09/08/2009 (INTAKE DATE'):

LINE PERSON ID 03 28610740

NAME: Piscitelli.winona PHONE: (516)750-0855

SEX DOB I ADDRESS F 07/06/2005 218 COUL ST EXT. ETHNICITY: Non-Hispanic

OH 44902

CROSS REFERENCE HISTORY INFORMATION: CASE WORKER INTAKE STAT STAGE ID OPEN 26367118 23963794 CLSO CLSD 23717296 23713813 23710886 23709353 PERSON ID AT INTAKE STAGE 28610740 28610740 2604 8170 28610740 28610740 28610740 INTAKE DATE 08/27/2009 1/420 21/06 0/820 62/06 06/26/2006 06/23/2006 06/22/2006 INV TYPE CPF CPF CPF CPF CPF CPF *DETERMINATION* DATE TYPE ROLE Confirmed Maltreated 02/07/2007 UNF Non-confirmed Maltreated 06/30/2006 SUS Maltreated Child 06/27/2006 SUS Maltreated Child Maltreated Child 06/26/2006 SUS Maltreated Child RELATIONSHIP Child Child Child Child child Child

FAM

24149309 22034447 21890342

* JURISDICTION * PRIMARY SECONDARY SUFF(047) SUFF(047) NASS(028) NASS(028) NASS(028) MASS(028) Page: 4 OF 5

Date Created : 09/08/2009 at 11:42

LDSS-2921 Statewide (Rev. 1/05)

APPLICATION DATE

DO NOT WRITE IN TOE SHADED AREAS OF THIS APPLICATION

REGISTRY NUMBER

PAGE1
NUMBER REUSE INDICATOR SERVICES TRANSACTION TYPE

D 02
ELIGIBILITY DETERMINED BY (WORKE DATE RECEIVED BY AGENCY j SOCIAL SERVICES DISTRICT TA AUTHORIZATION PERIOD MA AUTHORIZATION PERIOD PROVIDER AGENCY SPECIFY: FS AUTHORIZATION PERIOD

NEW
OPENING I I REOPEN RECERTIFICATION DATE

10

SIGNATURE OF PERSON WHO OBTAINED ELIGIBILITY INFORMATION

SERVICES AUTHORIZATION PERIOD

NEW YORK STATE f PLICATION FOR: TEMPORARY ASSISTANCE (TA) - MEDICAL ASSISTANCE (MA) - MEDICARE SAVINGS PROGRAM (MSP) - FOOD STAMP BENEFITS (FS) - SERVICES (S), including Foster Care (FC) - CHILD CARE ASSISTANCE (CC)

j are committed to assisting and supporting you in a professional and respectful manner with your goal of achieving self-sufficiency. You, in turn, must be committed to becoming self-sufficient and must be responsible for participating in activities to reach self-sufficiency including work activities for Temporary Assistance and Food Stamp Benefits where required. Whenever you see "Temporary Assistance" or "TA" on the application, it means "Family Assistance" and "Safety Net Assistance". We call both Public Assistance Programs "Temporary Assistance". These TA Pr^^^s^. meant to assist you only until you can fully support yourself and your family. 9*%$ {eljjjjf Please refer to the "How to Complete" instruction book (Pub-1301 Statewide) when completing this application. y t&tn .._ WS-i
CHECK EACH PROGRAM YOU OR ANY HOUSEHOLD MEMBER ARE APPLYING FOR DO YOU WANT TO RECEIVE NOTICES IN:
FIRST NAME
r l

D Temporary Assistance and Medical Assistance D Medicare Savings Program

fj f]

D Temporary Assistance D Services, including Foster Care

D Chiid Care in lieu of TA D Child Care Assistance

DI ly(EMRG

D Food Stamp Benefits! fits!

LJ SPANISH AND ENGLISH

M.I.

ENGLISH ONLY

WHAT IS YOUR PRIMARY r/h n n LANGUAGE? PJ ENGLISH U SPANISH U OTHER (specify) PLEASE PRINT CLEARLY
MARITAL STATUS

APPLICANT INFORMATION
LAST NAME

HOUSE NO. STREET ADDREgS

Mo,

APT. NO. CITY

^RE OF NAME (Complete if you receive your mail in care of another person)
\

IM, ..-,NG ADDRESS (IF DIFFERENT FROM ABOVE)

APT. NO.

COUNTY

AGENCY HELPING APPLICANT/CONTACT PERSON

i C0

Problem
AREA CODE ANOTHER PHC WHERE YOU"' REACHED PHONE NUMBER

C C O : "'

u.;

Fire Or Other Disaster

HOW LONG HAVE YOU LIVED AT YOUR PRESENT ADDRESS? DIRECTIONS TO HOME

YEARS

MONTHS

IS THIS A SHELTER? DYES DNO

o
= :3 O)
O

AREA CODE

Recently Lost Income

COUNTY

12 13 14 15 16 17

FORMER ADDRESS

APT. NO. CITY

STATE

ZIP CODE

Pending Eviction No Food

If You Are Applying For Food Stamp Benefits (FS), you have the right to turn in (file) this application the same day you get itJt must have at least your Name, Address (if you have one) and Signature below when you turn it in. If you are eligible, you will get FS back to the date you filed. You may be able to get FS quicl^Hf you have little or no income or liquid resources, or if your rent and utility expenses are more than your income and liquid resources. Talk to your worker if you have questions about this. HP
FS APPLICANT/REPRESENTATIVE SIGNATURE DATE SIGNED

Need Foster Care Need Child Care Other

10/15/09

THU 15:21 FAX 63185433,=

CPS MACARTHUR PARK ********************* *** TX REPORT *** **#*****#**#*********

@01 |0

TRANSMISSION OK TX/RX NO CONNECTION TEL CONNECTION ID ST. TIME USAGE T PCS, SENT RESULT
1386

99244602 JUSTKIDS 10/15 15:19 02 '15 7 OK

COUNTY OF SUFFOLK

STEVE LEVY SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF SOCIAL SERVICES Gregory J. Blass Commissioner

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From; LisaScafi e 631-654-9139 Pages:

Phone:

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***

V\h
n For Review U Please Comment D Please Reply D B*lease Recycle

H, Urgent

Comments:

(y^jL^fcJAv^-x^corx o

FOSTEir ARE PLACEMENT RE EW

I. REQUEST
FROM: Supervisor Name: Robert Leto Supervisor Phone #: 631-854-3142 Team #: 63 Date: 10-19-09 Worker Name: Lisa Scafide Worker Phone #: 631 -854-9139 LEGAL BASIS: Voluntary Placement Neglect Order JD or PINS Order

REQUEST TYPE: Post-placement review Planned Placement Change in level of care Resubmission (Pended from:

PLACEMENT INFORMATION: Date Placement Began: 9-16-09 Date Placement Ended: 9-23-09 (if applicable)

PLACEMENT REQUEST INFORMATION

SOO Case Number: 900898 Child's Name: Winona Piscitelli Mother's Name: Winona Palmiotti Child's CIN: dw78162e 7-6-05 Sex: f DOB: Race:

Legal Custodian? YES NO

Father's Name: Paul Piscitelli CHILD'S LIVING ARRANGEMENTS AT TIME OF REMOVAL: NOT IN DSS CUSTODY: With Birth Parent(s): Relative: Non-Relative Resource: IN DSS CUSTODY: Emergency boarding home: Regular Foster boarding home: Therap. Foster boarding home: Group Home: Institution (RTC): Institution (RTF): Psychiatric Hospital: Diagnostic Placement: Respite Bed: Supervised Indep, Lvg. Prog: Other, specify: Require Placement? No Yes In Care Already? No Yes

YES

DNO

Specify caretaker name / relationship, if applicable: Winona Palmiotti

Specify provider / agency name:

*MH^F^16-09thur 9-23-09

LIST CHILD'S SIBLINGS, IF ANY Name of Sibling(s) Age

n a

a a

If in care, Specify Provider/Agency Name:

Timothy Grant

20

-- 1

n n n n
PLACEMENT LEVEL REQUESTED:
Regular Foster Boarding home Therapeutic Foster boarding home Group home

n n n a

In 2C "~" :mothy was taken into protect. w custody. Neglect petition was filed by Sullivan County. Mother could not be found. Timothy aged out and is currently institutionalized upstate due to his inability to function independently in society

D D D D
Diagnostic Placement Respite bed Supervised Indep. Lvg. Prog.

Institution (RTC) Institution (RTF) OMH Group Home

CHILD'S PREVIOUS PLACEMENTS: (List actual or approx. dates and provider names. Include all out-of home placements whether relative, regular foster care, AIP/ Therapeutic foster care, Institutional care, diagnostic, psychiatric hospital, etc.) Placement Dates Provider / Agency Name: NA NA

RELATIVES / OTHER RESOURCES CONTACTED/ EXPLORED REGARDING PROVISION OF CARE OF CHILD Names of Relatives/ Resources: Paul Piscitelli Relationship: putative father paternity test completed on 9-30 Kinship Foster Care discussed:

~~~Z n

YES YES YES YES

U NO D NO

D NO

n NO

Describe Child and Family Needs/ Problems

(If request is for a change in level of placement or initial placement at a level higher than regular foster boarding home, you must include a thorough description of the child's current performance/ behaviors in home or placement setting and in school)

Winona was taken into protective custody on result she was initially placed in a therapetutic

09. At the time it was unknown the extent 01 jr home.

ices Winona was in need of. As a

In April of this year, mother and child Winona were living in Richland County Ohio. A report was rec'dby Richland County Child Protective when child arrived in the emergency room with burns to her hands and arms. Ohio had concerns and offered mother preventative services. Their concerns included the condition of the home, Winona drinking from a bottle, still wearing a diaper and unable to speak in more then one syllable words. Ms Palmiotti agreed to services. However, caseworkers were not able to make contact and sought an order to produce child. Her caseworker advised her of the court hearing. Ms Palmiotti then left Ohio and came to NY. A report was received by NY State Central Registry with Ms Palmiotti as the Subject. At the same time Ohio sought judical intervention to mandate services, Richland County and Suffolk County were in contact witheach other. Ms Palmiotti stated she was not returning to Ohio. Decision was made that Senior Cw Tase T71 offer Ms Palmiotti preventive services. She refused and a week later returned to Ohio. When she failed to show in court, Ohio requested custody of child However due to a breakdown in communication Ms Palmbtti received a voicemail that was not intended for and learned that Richland County was aking that her child be removed. Richland county obtained the order and when they went to remove the child they were unsuccessful. Ms Palmiottiwas on her way back to NY with her child. The judge in Richland County vacated the order when it was confirmed that mother was back in NY. Winona was observed by T71 sew K Tase and T63 sew L Scafide on different occassions. Both times child could not be interviewed as her speech was not able to be understood. Mother claims she had no knowledge that her child was speech delayed until she was told in April at the hospital. Mother now blames the burns as causing the child to regress. This cw as well as Nassau County caseworkers observed mother to have no control over child. Child would not follow verbal direction, she kicked , hit, spit jumped on her mother. Mother would physically restrain child in order to get her to stop engaging in a behavior. It was learned Winona had last been seen by a doctor in 2006.

Attach current diagnostic and other relevant materials (school, medical, mental health, etc.)

Supervisor:

/x^L

xx 7 // 7 /
^ //*/ /**

"

Asst. Director

II. REVIEW (For Committee Use Only) Review Date: COMMITTEE RECOMMENDATION: Postponed pending:
(Any/all information or materials requested must be submitted as soon as possible together w/this form)

No Placement by DSS: Placement should be explored through:

NOTE: A copy of the referral materials and written approval / denial of services by agency must be forwarded to the Committee.

Placement at the specified level: Psychiatric Hospital: Diagnostic Placement: Regular Foster Boarding Home: Therapeutic Foster Boarding Home: Group Home: Institution (RTC): Institution (RTF):

Without Regard to Avail. Resources

With Regard to Avail. Resources

OMK

oup Home: Respite Bed:

SupervisedJndep. Lvg. Program

Reviewed by: UI. PLACEMENT (Must be completed and returned to the Placement Review Committee) Child's Actual Placement Level: |~| [3 I | [ | No Placement Regular Foster boarding home Therapeutic Foster boarding home Group home D Institution (RTC) D Institution (RTF) Q OMH Group Home Date of Placement: I I I I I I Diagnostic Placement Respite bed Supervised Indep. Lvg. Prog.

Provider / Facility Name: Name of Contact Person: Does provider/agency contract with DSS? YES <] NO Q

Phone

503-7765

If placement is made at different level than that approved by Placement Review Committee, explain:

Supervisor: Distribution: Original - To worker

Asst. Director: Copies: Committee Members; Bureau Directors

FOSTEI :ARE PLACEMENT RE EW

I. REQUEST
FROM: Supervisor Name: Robert Leto Supervisor Phone #: 631-854-3142 Team #: 63 Date: 10-19-09 Worker Name: Lisa Scafide Worker Phone #: 631-854-9139 LEGAL BASIS: Voluntary Placement Neglect Order JD or PINS Order

REQUEST TYPE: Post-placement review Planned Placement Change in level of care Resubmission (Pended from:

PLACEMENT INFORMATION: Date Placement Began: 9-23-09 Date Placement Ended: present (if applicable)

PLACEMENT REQUEST INFORMATION

SOO Case Number: 900898 Child's Name: Winona Piscitelli Mother's Name: Winona Palmiotti Father's Name: Paul Piscitelli Child's CIN: dw78162e Sex: f DOB: 7-6-05 Race:

Legal Custodian? [X YES G NO

YES

DNO

CHILD'S LIVING ARRANGEMENTS AT TIME OF REMOVAL: NOT IN DSS CUSTODY: With Birth Parent(s): Relative: Non-Relative Resource: IN DSS CUSTODY: Emergency boarding home: Regular Foster boarding home: Therap. Foster boarding home: Group Home: Institution (RTC): Institution (RTF): Psychiatric Hospital: Diagnostic Placement: Respite Bed: Supervised Indep. Lvg. Prog: Other, specify: Specify provider / agency name:
X

Specify caretaker name / relationship, if applicable: Winona Palmiotti

^9-23-09 to present

LIST CHILD'S SIBLINGS, IF ANY

Name of Sibling(s) Age

Require Placement? No Yes

In Care Already? No Yes

If in care, Specify Provider/ Agency Name:

Timothy Grant

20

~1

In 20v 'tnothy was taken into protect, custody. Neglect petition was filed by Sullivan County. Mother could not be found. Timothy aged out and is currently institutionalized upstate due to his inablilty to function independently in society

D D D D
PLACEMENT LEVEL REQUESTED: Regular Foster Boarding home Therapeutic Foster boarding home Group home

D D D D D

D D D D D

D D D D D
Diagnostic Placement Respite bed Supervised Indep. Lvg. Prog.

Institution (RTC) Institution (RTF) OMH Group Home

CHILD'S PREVIOUS PLACEMENTS: (List actual or approx. dates and provider names. Include all out-of home placements whether relative, regular foster care, AIP / Therapeutic foster care, Institutional care, diagnostic, psychiatric hospital, etc.) Placement Dates Provider / Agency Name: NA NA

RELATIVES / OTHER RESOURCES CONTACTED/ EXPLORED REGARDING PROVISION OF CARE OF CHILD Names of Relatives/ Resources: Paul Piscitelli Relationship: putative father paternity test completed on 9-30 Kinship Foster Care discussed:

D D D D

YES YES YES YES

D D D

NO NO NO NO

Describe Child and Family Needs/ Problems

(If request is for a change in level of placement or initial placement at a level higher than regular foster boarding home, you must include a thorough description of the child's current performance/ behaviors in home or placement setting and in school)

Winona was taken into protective custody on - 09. At the time it was unknown the extent c 'ices Winona was in need of. As a result she was initially placed in a therapetutic . / home. After 8 days she was moved from th .rapeutic foster of Linda Madison . Ms Madison reported child displayed no aggression nor did she have any behavioral outbursts. Foster mother provided Winona with healthy diet, a developed a daily routine. Winona is 4 yrs and weight wise is off the growth chart Since entering foster care she has lost 51bs and has received 4 immunizations and blood work. She is currently in the foster home of a single parent. She attends full time daycare and is reportedly doing very well. There have been no acts of agression or behavioral outburst toward child or adults. There are apparent delays in her speech and a full evaluation has been requested through Just Kids.

Attach current diagnostic arfd other relevant materials (school, medical, mental health, etc.)

Supervisor:

Asst. Director:

II. REVIEW (For Committee Use Only) Review Date: COMMITTEE RECOMMENDATION: Postponed pending: (Any/all information or materials requested must be submitted as soon as possible together w/this form) No Placement by DSS: Placement should be explored through: NOTE: A copy of the referral materials and written approval / denial of services by agency must be forwarded to the Committee. Placement at the specified level: Psychiatric Hospital: Diagnostic Placement: Regular Foster Boarding Home: Therapeutic Foster Boarding Home: Group Home: Institution (RTC): Institution (RTF): OMH Group Home: Without Regard to Avail. Resources With Regard to Avail. Resources

Supervised Indeo. Lvg. Program Comments:

Reviewed by: III. PLACEMENT (Must be completed and returned to the Placement Review Committee) Child's Actual Placement Level:
0 ^ 1 I [~~| No Placement Regular Foster boarding home Therapeutic Foster boarding home Group home Institution (RTC) Institution (RTF) OMH Group Home

Date of Placement:
I I I I I I Diagnostic Placement Respite bed Supervised Indep. Lvg. Prog.

Provider / Facility Name: Name of Contact Person: Does provider/agency contract with DSS? YES [ | NO Q

Phone

503-7765

If placement is made at different level than that approved by Placement Review Committee, explain:

Supervisor: Distribution: Original - To worker

Asst. Director: Copies: Committee Members; Bureau Directors

10/15/2009 0 9 : 2 3 FAX 631 924 429?

JUST KIDS D AND T

. ,

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JUST KIDS an early childhood learning center Card-Held Enterprises., inc.

Logwood Road = Middle Island New Yorl: (03] ; 9:24-0008 Mailing Address: P.O. Box 12 * Middle Island New Yorl:

FACSIMILE COVER SHEET

THIS MEiiSAC .M;X i-iJiY CO* XPFT.ICXBLl'. AGEKT RESI>0: IS INTJS1WEP DULY FOI> THE 1 USE OP THE INDIVIDUAL OK JSHTITV TO WHICH IT IS ABDP.ESSEP .>.! IWPGlLMAT 3 (J)i TM*.T It l-'P.IVILEeKS . COMFIDENriAl.. AHt EXEMPT FROM DISCLOSURE UWDBK fcW. IF THE REAPE>: Of THIS MESSAGE T.g SOT THE IHTENPEI/ RJSCIPIBWr, OK AM EMPLOYEE OR BIBLE FOK DE7j.TVERINC- THE WEESAGE POI; THE 1MTEHD35IJ, YOU ARE HEF.EB1' WOTl'flED THAT ANY

DISSEMIHATIO: , DisTEiBunon 3* COPYIJMG or THIS COHKOSICATIOH is STUICTLV EHoasjeiTBo.

IF you HAVE

TK .5 COMMUlIICATJOf IV li'llKOF., PLEASE HOTiri1 OS IMMEDIATELY BV TELEPHONE ANt RETORR THE ORIGINAL MESSAGE TO OS AT OUR ADDRESS VIA THE U . S . POSTAL. SEEVICE. THANH YOU

DATE:
TO:

NO.

COMPAiT OR FIRM:
FROM:
RE:

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TOTAL NIIMBEE OF PAGES INCLUDING COVER SHEET:

7T * * * * * * f * * * * * * * * * *
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MESSAGE

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IF YOU DO WOT E.ECSIVE ALL PAGES, PLEASE (631} 9 2 4 - 0 0 0 8 FAX HOTSBSE ( 5 3 1 ) S 2 4 - 4 6 0 2 CALL

10/15/2009 09:24 FAX 631 924 4298

JUST KIDS D AND T

@]003

JUST KIDS an early childhood learning center

and

Diagnostic and Treatment Center

Cam-Held Enterprises, Inc,
Lo gw/ood Road- Middle Island* New York- (631) 924-0008 (631) 924-10000 Mailing Address; P.O. Box 12-Middle Island* New York 11953

CLIENT'S RIGHTS

Clients, and/or their guax-dians, at the Just Kids Learning Center ha/e the rig!it to: 1. 2. 3. 4. Receive servicss without regard to age, race, sex, national oricin, or religion. Be treated with consideration, respect, and dignity. Be d nf ormed of the services available at the center. Privacy and confidentiality of all information and records.

5 . Refi se to continue the evaluation process and to be fully inf; rmed of the outcome of this action. 6. Reft se to participate in experimental research.

7 . obt; in from the center, complete and current evai uation reports written in terms the guardian can be reasonably expected to understand. 8 . Voi ,'e grievances and recommend changes in policies and ser-ices to the center's staff, the New York Department of Hea.th, or the; school district without the fear of reprisal. 5. Exp :ess complaints about the care and services provided, and to lave the center investigate such complaints. The center is responsible for providing the client's guardian with wri :ten response within 30 days if requested, indicating the fin lings of the investigation. If the guardian is not satisfied by the center's response, a complaint can be filed wit i the New York State Department of Health Systems Maragement or the school district; and Approve or reEuse the release or disclosure of the contents of zhe evaluation reports to anyone except as required by lav ,

10.

10/15/2009 09:24 FAX 631 924 4298

JUST KIDS D AND T

i]004

C l i e n t ' s Rights 11.

Page 2

Be informed of the charges for service, eligibility for third-part reimbursements and, when applicable, the ava,lability of free or reducd cost care. Privacy and confidentiality of all information and records per mining to the patient's treatment.

12.

10/14/2009 0 8 : 4 1 FAX 631 924 4298

JUST KIDS D AND T

El 001

JUST KIDS an early childhood learning center

Cam-Held Enterprises, Inc. Road < Middle IsJaod New YarJ: (631 j 924-OOOfi Address: P.O. Bo?; 1.2 - Middle Island New Yon: 11953

FACSIMILE COATEE SHEET

THIS MEESAG: is INTENDED OH:V FOE TUP USE OP THE IHDIVIDDAJ, OK JSMTITY TO WHJCK IT is
;!.. 1-ir.V COM' -.!> IWFUWii.TiUli THW It PRIVIXiBGBD . CONFIDENTIAL XMt EXEMPT' FJIQK PISCLOSUBE UHDElt APPJ..1CABLE L .V?. IF TUB HEAITSr: OF THIS MESSAGE IE NOT THC INTENDS); KBCIP IfflHT. OR AM BMFL.OYEE OFi F.ESroK IBLE l f UK DELIVEIIIWC- TH2 J1ESSAC2 fOJ: THE INTRUDED, YOU 7JUS HEREBY NOTIFIED THAT AHV IOK DI6TKIBDTIOM OK COPV1MG OF THIS COMHUWIOiTIOH IE STRICLY 3rftOH:EITED. IP VOU H A V E '

TH: s COMMUIUCATION IB EKROP., PLEASF. NOTIFY as IMMEDIATELY BV TEMFJ-IONE AND P-ETHRN THE
ORIGINAL MESSAGE TO U AT OUR ADD1(ESS VIA THR 0 S. THAHi! YOU P'OSTAl* SERVICE,

DATE,

NO.:

COMPAHi" OR FIRM: FROM

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* * * * * ******** ******** *********************

TOTAL
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TRANSPORTATION SERVICES REQUISITION/RECORD

Case Name: Winona Palmiotti Case Number: SOO900898 Court Ordered: Yes 13 No D

Requisition Date: 9-29-09 Child/Children and DOB: Winona Piscitelli 7-6-05 |~| Deliver items [~| Drop off records

Type of Activity: 153 Supervised Visit with transportation l~l Supervised Visit without transportation CD Transportation Only

Visit or Activity to Commence on: ASAP Frequency of Visit: EH1 time ^weekly d|bi-weekly Length of Visit: 2 hours Time of visit: (check) ^am ^afternoon [^evening DSaturday (IF VISIT MUST BE A SPECIFIC TIME OR DAY, PLEASE INDICATE): Foster Parent or Custodian: Address:' Shirley Home PhonesMHjj^B

Cell:

Person(s) Authorized to have visit and relationship to children: Winona Palmiotti mother Home Phone: Cell: 516 238-0371 PICK UP location(s) (list all):!

Visitation Site/Address: MacArthur Bldg RETURN location(s): same as pick up location

Please check all that apply: Order of Protection (Attach copy) Letter from custodian giving permission for DSS to transport (Attach copy) Qlndividuals not permitted at visit: ****mother tries to bring other people only person approved is Barbara Grant***** MEDICAL INFORMATION (check all that apply, please note individual with condition/allergy): DAllergy (list allergy) D Asthma . QSeizure disorder QOther QSpecial equipment QNone Comments: Supervised visit with mother only. Caseworker: L Scafide Assigned to: Team# 63 Extension: 49139 Start Datef W/V/^ Time:
|QS*

Transportation Unit cannot handle request at this time:

10/14/09

WED 10:56 FAX 631854335'

CPS MACARTHUR PARK ********************* *** TX REPORT ***

*********************

TRANSMISSION OK TX/RX NO CONNECTION TEL CONNECTION ID ST. TIME USAGE T PCS. SENT RESULT
1381

97279527
10/14 10:55 01'02 3 OK

COUNTY OF SUFFOLK
STEVE LEVY
SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF SOCIAL SERVICES GREGORY J. BLASS
COMMISSIONER

FAX TRANSMITTAL COVE * SHEET

Date: From:
To: Re:

Number of pages, including this cover sheet: Fax Number sent to: ' Date: Time:

CONFIDENTIALITY NOTi CE
The documents which accompany this telefax transmiss on sheet contain information which is confidential and/or ifinaiu/ nm/;ion^ -. ,h.i~U :. :,-*.

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OFFICE OF CHILDREN AND FAMILY SERVICES CHILD PROTECTIVE SERVICES INTAKE REPORT CASE NAME MERGE TO CASE ID INTAKE CASE ID CALL/INTAKE STAGE ID

******* WARNING ******* CONFIDENTIAL INFORMATION AUTHORIZED PERSONNEL ONLY

Palmiotti .winona M
24158873 26384552

T'c K . \
SUMMARY
N

. -ASSIFICATION
INTAKE TYPE DUP. OF STAGE ID

, REPORTED / REPORTED

09/09/2009 04:41 PM
Initial

PRIMARY WORKER
* COUNTY/ZONE SECONDARY WORKER COUNTY/ZONE WORKER TAKING INTAKE

Addi son, vi rgi nia

NASSAU 28450580

CPS - Familial Sensitive issues : N

Worker Safety : N

COUNTY/ZONE

State Central Register special Handling : N

(A28) / I / '

/ f 1} /)
'f I i I

LIST OF PRINCIPALS Line ADDR # . . NAME 01 P01 jjfc winona AKA Palmiotti RELATIONSHIP Mother ROLE Algd Sub SEX F DOB CAGE) 04/07/1973 (36) TYPE DOD PERSON ID 28610736 REL Y LANG EN Li ne 01

ETHNICITY / RACE: Non-Hispanic

/ white / White / White

02

P01

Paul Pi sci tel1i ETHNICITY / RACE: Non-Hispanic - winona Pi sci tell i ETHNICITY / RACE: Non-Hi spanic

Bio. Father child

unknown Mai Child F

28610737 28610740

EN

02

03

P01

07/06/2005 (4 )

EN

03

ADDR # 01

STREET 318 ELLISON AVE

9
CHILDREN ALLEGATIONS

REPORTED ADDRESS INFORMATION CITY WESTBURY SI NY ZIP CNTY CD ADDR TYPE PHONE EXT PHONE TYPE ADDR #

1 5 0 NASS 1 9

RS

01

ALLEGATION DETAIL Line MALTREATED/ABUSED Line 01 ALLEGED SUBJECTfS) winona Palmiotti

03

winona Piscitell i

Inadequate Guardianship Lack of Medical Care

Date Created : 09/14/2009 at 09:28 Page: 1 OF 6

OFFICE OF CHILDREN AND FAMILY SERVICES CHILD PROTECTIVE SERVICES INTAKE REPORT CASE NAME MERGE TO CASE ID INTAKE CASE ID CALL/INTAKE STAGE ID

******* WARNING ******* CONFIDENTIAL INFORMATION AUTHORIZED PERSONNEL ONLY

Palmiotti .Winona M 24158873 26384552

call Narrative Narrative: The child, win9na (age 4), has severe developmental delays. The child still drinks from a bottle, is unable to form sentences when speaking, and wears a diaper. The mother, Winona, has mental health issues and has done nothing to address her child's developmental issues. The nrother has fled the State of Ohio after learning her child was being removed from her care. The mother has a history of hitting the child and being inappropriate with the child in the past. The role of the father, Paul, is unknown at this time.

Miscellaneous information: The source gave | ^ | lf as an alternate telephone number. The mother left Ohio for Suffolk ^ H Hl t county before the child could be removed fromTlSr^HW^^After arriving in Suffolk cty, the mother was observed striking the child in the chest while at a cty office waiting for housing assistance. The mother then fled Suffolk Cty and went back to Ohio. The mother has since returned to NY and is staying with the child's father, Paul, in Nassau Cty. There are several closed cases in connections regarding the family.

Locating information: The child is believed to be with the mother.

Date Created : 09/14/2009 at 09:28 Page: 3 OF 6

OFFICE OF CHILDREN AND FAMILY SERVICES CHILD PROTECTIVE SERVICES INTAKE REPORT CASE NAME MERGE TO CASE ID INTAKE CASE ID CALL/INTAKE STAGE ID

******* WARNING ******* CONFIDENTIAL INFORMATION AUTHORIZED PERSONNEL ONLY

Palmiotti .Winona M 24158873 26384552

call Narrative Narrative: The child, win9na (age 4), has severe developmental delays. The child still drinks from a bottle, is unable to form sentences when speaking, and wears a diaper. The mother, Winona, has mental health issues and has done nothing to address her child's developmental issues. The nrother has fled the State of Ohio after learning her child was being removed from her care. The mother has a history of hitting the child and being inappropriate with the child in the past. The role of the father, Paul, is unknown at this time.

Miscellaneous information: The source gave | ^ | lf as an alternate telephone number. The mother left Ohio for Suffolk ^ H Hl t county before the child could be removed fromTlSr^HW^^After arriving in Suffolk cty, the mother was observed striking the child in the chest while at a cty office waiting for housing assistance. The mother then fled Suffolk Cty and went back to Ohio. The mother has since returned to NY and is staying with the child's father, Paul, in Nassau Cty. There are several closed cases in connections regarding the family.

Locating information: The child is believed to be with the mother.

Date Created : 09/14/2009 at 09:28 Page: 3 OF 6

OFFICE OF CHILDREN AND FAMILY SERVICES CHILD PROTECTIVE SERVICES INDIVIDUAL REPORT OF INVOLVEMENT CASE NAME MERGE TO CASE ID INTAKE CASE ID CALL/INTAKE STAGE ID

******* WARNING ******* CONFIDENTIAL INFORMATION AUTHORIZED PERSONNEL ONLY

Palmiotti, Winona M 24158873 26384552

PERSON INFORMATION AS OF 09/09/2009 (INTAKE DATE): LINE PERSON ID 01 28610736 NAME:

RELATED:Y

paTmiotti,Winona M
PHONE: (516)216-4925

SEX DOB I ADDRESS F 04/0771973 318 ELLISON AVE EXT. ETHNICITY: Non-Hispanic

cm WESTBURY
RACE: white

SI
NY

CJJ 590

CROSS REFERENCE HISTORY INFORMATION: CASE ID 24158873 SUFFC047) 24149309 22034447 21890342 CASE WORKER INTAKE STAT SAFETY STAGE ID OPEN N 26384552 CLSD CLSD CLSD PERSON ID AT INTAKE STAGE 28610736 28610736 28610736 28610736 28610736 28610736 28610736 28536551 2228684 2228684 2228684 23763124 23763124

INV 'DETERMINATION* INTAKE TYPE DATE TYPE ROLE DATE 09/09/2009 CPF Alleged
08/27/2009 12/14/2006 06/28/2006 06/26/2006 06/23/2006 06/22/2006 06/02/2006 10/17/2005

subject

RELATIONSHIP Mother Mother

FAM

* JURISDICTION * PRIMARY SECONDARY NASS(028) SUFF(047) SUFF(047) NASS(028) MASS(028) NASS(028) MASS(028) NASS(028) SULL(048) SULL(048) SULL(048) SULL(048) CHEN(OOS) CHEN(008)

N N Y

21383850 NASS(028) NASS(028) 21345981 NASS(028) DELA(012)

CLSD

26367118 23963794 23717296 23713813 23710886 23709353 23677686 23274150 23119887 22692294 22688610 22628150 22627145

CPF CPF CPF CPF CPF CPF CPF CPF

0/820 90/09 02/07/2007 06/30/2006 06/27/2006

IND UNF SUS SUS

Confirmed Subject

06/26/2006 SUS 07/21/2006 UNF 12/20/2005 IND 09/07/2005 UNF 0/920 81/04 09/21/2004 06/15/2004 08/02/2004

08/02/2005 CPF 08/18/2004 0/420 81/04 06/12/2004 06/11/2004

CLSD

CPF CPF CPF CPF

SUS IND SUS IND

Non-Confirmed Subject Alleged subject No Role unknown No Role Non-Confirmed Subject confirmed subject Non-confirmed Subject Alleged Subject Confirmed Subject Alleged subject
Confirmed Subject

Mother Mother Mother Mother Mother Mother

Mother

Parent Mother Mother

Parent Mother

22616598 C028) ^.o27081 20789757 20323277 931644 CLSD CLSD CLSD CLSD
N

587916 587916 2281999 23763124 23763124 23763124 21562047

06/03/2004 CPF 12/14/2001 12/14/2001 11/06/2001 11/06/2001 10/15/2001 05/06/1999 06/05/1989 05/03/1989 0/218 50/99 03/30/1989 05/05/1989 0/618 41/99 0/418 40/99 03/30/1989

08/02/2004 IND 12/28/2001 12/28/2001 12/04/2001 12/10/2001 12/04/2001 07/27/1999 06/23/1989 06/23/1989 0/318 62/99 06/23/1989 0/618 61/99 0/618 61/99 06/16/1989 06/16/1989

Confirmed Subject Confirmed Subject Confirmed Subject Confirmed Subject Confirmed Subject Confirmed Subject Maltreated Child No Role Abused Child No Role Confirmed subject Confirmed Subject Confirmed Subject Confirmed subject
Confirmed Subject

Mother
Grandparent

CHEN(OOS) CHEN(008) CHEN(008) CHEN(008) CHEN(008)

N N N

930163

CLSD

21641667 21641661 21597691 21597676 21572032 20654510 1238151 1238149 1238147 1238145 1236192 1236190 1236188 1236186

CPF CPF CPF CPF CPF CPF CPF CPF CPF CPF CPF CPF CPF CPF

IND IND IND IND IND IND IND IND IND IND IND IND IND IND

Mother
Grandparent Mother

Mother Mother unrel . Home mem.

Unrel . Home mem. Unrel . Home mem. unrel . Home mem.

CHEN(OOS)
CHEN(OOS) NASS(028) NASS(028) NASS(028) NASS(028) NASS(028) NASS(028) NASS(028) NASS(028)

Parent parent Parent Parent

PERSON MERGE INFORMATION _ CLOSED PERSON PERSON ID 28536551 21562047 MERGE DATE 06/23/2006 06/23/2006

DEMOGRAPHICS:
NAME

SPLIT DATE

unk.unk
Grant, Winona

SEX F F

DOB
10/07/1945

TYPE

ETH XNR WH

RACE

POD

Date created : 09/14/2009 at 09:28 Page: 4 OF 6

OFFICE OF CHILDREN AND FAMILY SERVICES CHILD PROTECTIVE SERVICES INDIVIDUAL REPORT OF INVOLVEMENT CASE NAME MERGE TO CASE ID INTAKE CASE ID CALL/INTAKE STAGE ID

******* WARNING ******* CONFIDENTIAL INFORMATION AUTHORIZED PERSONNEL ONLY

palmiotti , Winona M 24158873 26384552

04/07/1973 04/07/1973 04/07/1973 04/07/1973
WH AA WH AA

2228684 587916 23763124 2281999

06/23/2006 06/23/2006 06/23/2006 06/23/2006

palmiotti .Winona M Grant, winonna Palmiotti , Winona M Marzocco , Wi nona

RELATED:Y

F F F F

)N INFORMATION AS OF 09/09/2009 (INTAKE DATE"): LINE PERSON ID ~5T 28610737 NAME: Piscitelli,Paul PHONE: (516)333-2672

SEX DOB T ADDRESS M 05/27/1972 318 ELLISON AVE EXT. ETHNICITY: Non-Hispanic

CITY WESTBURY

ST ZIP CTY NY 11590 028

CB

RACE: white

CROSS REFERENCE HISTORY INFORMATION: CASE WORKER INTAKE STAT SAFETY STAGE ID TAGE 6384 OPEN N 26384552 PERSON ID AT INTAKE STAGE INTAKE DATE
INV 'DETERMINATION* TYPE DATE TYPE ROLE unknown CPF CPF CPF CPF CPF CPF CPF

24158873 SUFF(047) 21890342

28610737 28610737 28610737 28610737 28610737 28536552 27437584 27437584

09/09/2009 06/28/2006 06/26/2006 06/23/2006 06/22/2006 06/02/2006 10/17/2005

RELATIONSHIP Biological Father Biological Biological Biological Biological Biological Biological Father Father Father Father Father Father

FAM

* JURISDICTION * PRIMARY SECONDARY NASS(0~28) NASSC028) NASSC028) NASSC028) NASSC028) NASS(028) SULL(048) SULLC048)

CLSD

21383850 NASS(028) NASS(028)

CLSD

23717296 23713813 23710886 23709353 23677686 23274150 23119887

06/30/2006 06/27/2006 06/26/2006 07/21/2006 12/20/2005

sus Alleged Subject sus Alleged Subject

SUS UNF IND

Alleged Subject Alleged Subject Non-Confirmed Subject Confirmed Subject

08/02/2005 CPF 09/07/2005 UNF No Role

parent Substitute

PERSON MERGE INFORMATION - CLOSED PERSON DEMOGRAPHICS: 'SON ID 37584 ^-.,36552

1

MERGE DATE 06/23/2006 06/23/2006

SPLIT DATE

NAME

PI sci tel 1 i , Paul unk.unk

RELATED : Y

SEX M M

DOB OS/27/1372

TYPE

ETH WH XNR

RACE

POD

PERSON INFORMATION AS OF 09/09/2009 (INTAKE DATE): LINE PERSON ID 03 28610740 NAME: Piscitelli .Winona

SEX DOB T ADDRESS F 07/06/2005 318 ELLISON AVE

CITY WESTBURY

B
NY 1 5 0 028 19

RACE: white

CROSS REFERENCE HISTORY INFORMATION: CASE WORKER INTAKE CASE ID 24158873 SUFF(047) 24149309 22034447 21890342
ID 84552

PERSON ID AT INTAKE STAGE

INTAKE DATE

INV *DETERMINATION* TYPE DATE TYPE ROLE

RELATIONSHIP

FAM

28610740 28610740 28610740 28610740

09/09/2009 CPF

Maltreated Child

Child

* JURISDICTION * PRIMARY SECONDARY NASS(028) SUFF(047) SUFF(047) NASS(028)

CLSD CLSD CLSD

N N Y

26367118 23963794 23717296

08/27/2009 CPF 09/08/2009 IND confirmed Maltreated child 12/14/2006 CPF 02/07/2007 UNF Non-confirmed Maltreated Child 06/28/2006 CPF 06/30/2006 SUS Maltreated Child Child Date created : 09/14/2009 at

09:28 page: 5 OF 6

OFFICE OF CHILDREN AND FAMILY SERVICES CHILD PROTECTIVE SERVICES INDIVIDUAL REPORT OF INVOLVEMENT

******* WARNING ******* CONFIDENTIAL INFORMATION AUTHORIZED PERSONNEL ONLY

CASE NAME
MERGE TO CASE ID INTAKE CASE ID CALL/INTAKE STAGE ID

Palmiotti ,wi nona M

24158873 26384552

71383850
; ^ 0 8 ( 2 )

CLSD

23713813 23710886 23709353 23677686 23274150 23119887

28610740 28610740 28610740 28536560 27437585 27437585

06/26/2006 06/23/2006 06/22/2006 06/02/2006 10/17/2005

CPF CPF CPF CPF CPF

06/27/2006 SUS Maltreated child Child Maltreated child Child 06/26/2006 SUS Maltreated child Child 07/21/2006 UNF Non-confirmed Maltreated Child 12/20/2005 IND Confirmed Maltreated Child

MASS ( 2 ) 08 MASS ( 2 ) 08 NASS(028) MASS ( 2 8 0 ) SULL(048) SULL(048)

N(2) ^08

08/02/2005 CPF 09/07/2005 UNF Non-confirmed Maltreated Child

PERSON MERGE INFORMATION - CLOSED PERSON DEMOGRAPHICS: PERSON ID MERGE DATE SPLIT DATE

27437585 28536560

06/23/2006 06/23/2006

NAME piscitelli ,Winona

Unk,

SEX F

DOB 0/620 70/05

TYPE

ETH WH

RACE

POD

11/01/2005

XNR

PERSON INFORMATION AS OF 09/14/2009 (PRINT DATE): LINE PERSON IP NAME: SEX

DOB

I ADDRESS
318 ELLISON AVE

CITY WESTBURY

SI ZIP

CTY

CD

01 28610736
02 03 28610737 28610740

Palmiotti .winona M
PHONE: (516)216-4925 Piscitelli .Paul PHONE: (516)333-2672 Piscitelli,winona PHONE: (516)750-0855

F 04/07/1973
EXT.
M EXT. F 05/27/1972

NY 11590 028

ETHNICITY: Non-Hispanic
318 ELLISON AVE ETHNICITY: Non-Hispanic 07/06/2005 318 ELLISON AVE

RACE: white
WESTBURY RACE: white WESTBURY

NY 11S90 028

NY 11590 028

EXT.

ETHNICITY: Non-Hispanic
*****

RACE: white
ENO OF

REPORT

*****

Date Created : 0 / 4 2 0 at 09:28 Page: 6 OF 6 91/09

SCase Composition - Palmiotti.Winona M Re Options Help

M/S

Name PalmiottLWinona M PiscitellLPaul PiscitellLWinona

gr

DOB
04/07/1973

05/27/1972 07/06/2005

Age Sex Ethnicity Race Non-Hispanic White 36 37 M Non-Hispanic White

Non-Hispanic White

R^l/int
Mother Biological Father Child

o
Person List*";"J Peteon" Search. ..

7/
OFFICE OF CHILDREN AND FAMILY SERVICES CHILD PROTECTIVE SERVICES INTAKE REPORT CASE NAME MERGE TO CASE ID INTAKE CASE ID CALL/INTAKE STAGE ID Palmiotti,winona M ******* WARNING ******* CONFIDENTIAL INFORMATION AUTHORIZED PERSONNEL ONLY

SUMMARY

~;TE REPORTED
1 'E REPORTED /^ OSSIFICATION / INTAKE TYPE / DUP. OF STAGE ID worker Safety :\N

:e7820r^. ^9570i~v
1 : 9 AM 10 - V x ^ " CPS - Familial \ Additional info 1 I / Sen sitive issues : N

PRIMARY WORKER Boehmer , Nora COUNTY/ZONE SUFFOLK SECONDARY WORKER COUNTY/ZONE WORKER TAKING INTAKE 8349 COUNTY/ZONE state Central Register special Handling : N

(4) A7

\^_^/
Line ADDR f 01 pOl NAME winona Palmiota ETHNICITY / RACE: Non-Hispanic Paul Piscitelli ETHNICITY / RACE: Non-Hispanic winiona Piscitelli ETHNICITY / RACE: Non-Hi spanic AKA / White Bio. Father / White Child / white RELATIONSHIP Mother

LIST OF PRINCIPALS ROLE unknown SEX F DOB (AGE") TYPE 04/07/1973 ( 6 3) POD PERSON ID 28610736 REL Y LANG EN Line 01

02

POl

Algd Sub

( )
07/06/2005 ( ) 4

28610737

EN

02

03

POl

Mai Child

28610740

EN

03

REPORTED ADDRESS INFORMATION ADDR # 01 STREET 318 ELLISON AVE CITY WESTSURY SI NY ZIP CNTY CD ADDR TYPE RS PHONE EXT PHONE TYPE ADDR # 01

11590 NASS

REPORTER RELATIONSHIP:

INFORMATION AGENCY SUMMARY OF FINDINGS : Y

BS
PHONE :

EXt.

BS
Report Narrative on the Next Page Date Created : 09/08/2009 at 11:42 Page: 1 OF 5

OFFICE OF CHILDREN AND FAMILY SERVICES CHILD PROTECTIVE SERVICES INTAKE REPORT CASE NAME MERGE TO CASE ID INTAKE CASE ID CALL/INTAKE STAGE ID

******* WARNING ******* CONFIDENTIAL INFORMATION AUTHORIZED PERSONNEL ONLY

Palmiotti ,winona M
24157497 26381660

Call Narrative:Add info

Narrative:

Miscellaneous Information: The family is from Ohio and there is an open child protection case there. Mother has been uncooperative and she fled with her child Winona and went to New York. Child is delayed and is suppose to be receiving services in Ohio. The source is requesting a courtesy visit by the county. There is an open case in Suffolk county. Source may also be contacted at

Locating information:

Date created : 0 / 8 2 0 at 11:42 Page: 2 OF 5 90/09

OFFICE OF CHILDREN AND FAMILY SERVICES CHILD PROTECTIVE SERVICES INDIVIDUAL REPORT OF INVOLVEMENT CASE NAME MERGE TO CASE ID INTAKE CASE ID CALL/INTAKE STAGE ID

******* WARNING ******* CONFIDENTIAL INFORMATION AUTHORIZED PERSONNEL ONLY

Palmiotti .winona M 24157497 26381660

PERSON INFORMATION AS OF 09/08/2009 (INTAKE DATE): LINE PERSON ID 01 28610736 NAME: PaTmiotti,winona M PHONE: (516)216-4925

RELATED:Y CITY MANSFIELD OH 44902

SEX DOB I ADDRESS F 04/0771973 218 COUL ST EXT. ETHNICITY: Non-Hispanic

RACE: white

CROSS REFERENCE HISTORY INFORMATION:

CASE 24149309 22034447 21890342

WORKER INTAKE SIAT SAFETY OPEN N 26367118 CLSD N 23963794 CLSD Y 23717296

PERSON ID AT INTAKE STAGE 28610736

INTAKE

21383850
NASS(028) NASS(028)

CLSD

23713813 23710886 23709353 23677686 23274150

28610736 28610736 28610736 28610736 28610736 28536551 2228684 2228684 2228684 23763124 23763124 587916

DATE 08/27/2009 12/14/2006 06/28/2006 06/26/2006 06/23/2006 06/22/2006 06/02/2006 10/17/2005 08/02/2005 08/18/2004 08/14/2004 06/12/2004 06/11/2004 06/03/2004 12/14/2001 12/14/2001 11/06/2001 11/06/2001 10/15/2001 05/06/1999 06/05/1989 05/03/1989 05/02/1989 03/30/1989 05/05/1989 04/16/1989 04/04/1989 03/30/1989

INV *DETERMINATION* TYPE ROLE TYPE DATE Confirmed Subject CPF CPF 02/07/2007 UNF Non-Confirmed Subject CPF 06/30/2006 SUS Alleged subject CPF 06/27/2006 SUS No Role Unknown CPF CPF 06/26/2006 SUS NO Role CPF 07/21/2006 UNF Non-Confirmed Subject CPF 12/20/2005 IND Confirmed Subject
CPF CPF CPF CPF CPF

RELATIONSHIP

FAM

Mother Mother Mother Mother Mother Mother Mother Mother Parent Mother Mother Parent Mother Mother Grandparent Mother Grandparent Mother Mother Mother unrel. Home Unrel. Home Unrel. Home Unrel. Home parent parent parent parent

* JURISDICTION * PRIMARY SECONDARY SUFF(047) SUFFC047) NASS(028) NASSC028) MASS(028) NASS(028) NASS(028) SULL(048) SULL(048) SULL(048) SULL(048) CHEN(008) CHEN(008)

23119887
CLSD
N

09/07/2005 08/19/2004 09/21/2004 06/15/2004 08/02/2004 08/02/2004 12/28/2001 12/28/2001 12/04/2001 12/10/2001 12/04/2001 07/27/1999 06/23/1989 06/23/1989 06/23/1989 06/23/1989 06/16/1989 06/16/1989 06/16/1989 06/16/1989

UNF SUS IND SUS IND

Non-Confirmed Subject Alleged Subject Confi rmed Subject Alleged subject Confirmed Subject Confirmed Subject Confirmed Subject Confi rmed Subject confirmed Subject confirmed Subject Confirmed Subject Confirmed Subject Maltreated Child No Role Abused child No Role Confirmed Subject Confirmed Subject Confirmed Subject confirmed Subject

21345981
NASS(028) DELA(012)

22692294 22688610 22628150 22627145 22616598

CPF CPF CPF CPF CPF CPF CPF CPF CPF CPF CPF CPF CPF CPF CPF

IND IND IND IND IND IND IND IND IND IND IND IND IND IND IND

CHEN(008) CHEN(008) CHEN(008) CHEN(008) CHEN(008) CHEN(008) CHEN(008) NASS(028) MASS(028) NASS(028) NASS(028) NASS(028) NASS(028) NASS(028) MASS(028)

, <?27081 -.,89757 20323277 931644 930163

CLSD CLSD CLSD CLSD

N N N
N

CLSD

21641667 21641661 21597691 21597676 21572032 20654510 1238151 1238149 1238147 1238145 1236192 1236190 1236188 1236186

587916 2281999 23763124 23763124 23763124 21562047

mem. mem. mem. mem.

PERSON MERGE INFORMATION - CLOSED PERSON DEMOGRAPHICS : PERSON ID MERGE DATE SPLIT DATE

28536551 21562047 2228684

06/23/2006 06/23/2006 06/23/2006

Unk.unk Grant, Winona Palmiotti .winona M

NAME

SEX
F

DOB

TYPE

ETH XNR

POD

F F

10/07/1945 04/07/1973

WH WH Date Created : 09/08/2009 at 11:42 Page: 3 OF 5

OFFICE OF CHILDREN AND FAMILY SERVICES CHILD PROTECTIVE SERVICES INDIVIDUAL REPORT OF INVOLVEMENT CASE NAME MERGE TO CASE ID INTAKE CASE ID CALL/INTAKE STAGE ID Pal mi otti , winona M 24157497 26381660

******* WARNING ******* CONFIDENTIAL INFORMATION AUTHORIZED PERSONNEL ONLY

21383850 NASS(028) NASSC028)

CLSD

23677686 23274150 23119887

28536560 27437585 27437585

06/02/2006 CPF 10/17/2005 CPF 08/02/2005 CPF

07/21/2006 UNF 12/20/2005 IND 09/07/2005 UNF

Non-confirmed Maltreated Child Confirmed Maltreated Child Non-confirmed Maltreated child

NASSC028) SULLC048) SULL(048)

oON MERGE INFORMATION - CLOSED PERSON DEMOGRAPHICS: PERSON ID 27437585 28S36560 MERGE DATE 06/23/2006 06/23/2006 SPLIT DATE NAME Pi sci tel 1 i , wi nona Unk,

sac
F U

DOB 07/06/2005 11/01/2005

TYPE

ETH WH XNR

BACE

POD

PERSON INFORMATION AS OF 09/08/2009 (PRINT DATE') : LINE PERSON IP 01 28610736 NAME: Pal mi otti , winona M PHONE: (516)216-4925 02 28610737 Piscitelli.Paul PHONE: (516)333-2672 03 28610740 Pi sci tel1i,wi nona PHONE: (516)750-0855 SEX DOB T ADDRESS 218 COUL ST RACE: white WESTBURY RACE: white MANSFIELD RACE: white
END OF

CITY MANSFIELD

SI ZIP

CTY

CD

F 04/07/1973 EXT. M EXT. F EXT.

OH 44902

ETHNICITY: Non-Hispanic OS/27/1972 318 ELLISON AVE

NY 11590 028

ETHNICITY: Non-Hispanic 07/06/2005 218 COUL ST

OH 44902

ETHNICITY: Non-Hispanic *****

REPORT *****

Date Created : 0 / 8 2 0 at 1 : 2 page: 5 OF 5 90/09 14

COUNTY OF SUFFOLK

STEVE LEVY SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF SOCIAL SERVICES

Gregory J. Blass

Commissioner

Fax
iGl
Fax:
Phone: From: LisaScafide 631-854-9139

- M

Pases;
Date:

CC:
Urgent D For Review D Please Comment Q Please Reply D Please Recycle

Comments:

Thank you for your prompt attention to this matter Sincerely -t \

LisaScafide Team63/102 Confidentiality Notice: The documents, which accompany this telefax transmission sheet, contain information which is confidential and/or legally privileged, and which is intended only for the use of the person or entity named above. If you have received this transmission in error you are hereby notified that any disclosure, copying distribution, or the taking of any action in reliance of the contents of this information is strictly prohibited and that the documents must be returned to this office immediately. If you have received this transmission in error, or if any parts of it are missing or illegible, please notify us at 631-854-9139

BOX 18100

HAUPPAUGE, N.Y. 11788 - 8900

(631)854-9935

TRANSPORTATION SERVICES REQUISITION/RECORD Case Name: Winona Palmiotti Case Number: SOO900898 Court Ordered: Yes E] No D Requisition Date: 9-29-09 Child/Children and DOB: Winona Piscitelli 7-6-05 d Deliver items [U Drop off records

Type of Activity: ^ Supervised Visit with transportation [~1 Supervised Visit without transportation [U Transportation Only

Visit or Activity to Commence on: ASAP Frequency of Visit: [Hi time ^weekly [Ubi-weekly CUmonthly Length of Visit: 2 hours Time of visit: (check) <]am ^afternoon CHevening CUSaturday (IF VISIT MUST BE A SPECIFIC TIME OR DAY, PLEASE INDICATE): Foster Parent or Custodian: < Address: ' Shirley Home P h o n e : H K

Cell:

Person(s) Authorized to have visit and relationship to children: Winona Palmiotti mother Home Phone: Cell: 516 238-0371 PICK UP location(s) (list all)*

Visitation Site/Address: MacArthur Bldg RETURN location(s): same as pick up location Please check all that apply: ^Order of Protection (Attach copy) QLetter from custodian giving permission for DSS to transport (Attach copy) Qlndividuals not permitted at visit: ****mother tries to bring other people only person approved is Barbara Grant***** MEDICAL INFORMATION (check all that apply, please note individual with condition/allergy): [UAllergy (list allergy) dAsthma dSeizure disorder [Bother dSpecial equipment [IJNone Comments: Supervised visit with mother only. Caseworker: L Scafide Assigned to: _ Team#63 Extension: 49139 Start Date: Time:

Transportation Unit cannot handle request at this time: Transportation Coordinator Date

UOSS-4811 (REV. 8/04)

Family Eligibility Checklist, Page 1 of A

FAMILY ELIGIBILITY CHECKLIST

Instructions: Complete a separate checklist Tor each family case.

CASE INFORMATION Note: Citizenship or qualified immigration status required for eligibility.; ' Unit/Worker Numbe Case Name Case Number FA/SN Clearance Date /O I /J/o9 FA/SN Recipient D Yes D WMS Screen Print SSI Clearance Dale /6/;Y I&9 SSI Recipient D Yes Q'No SECTION II. TANF-EAF ELIGIBILITY A. EMERGENCY SITUATION. This emergency situation I Q3 D C3 D C3 HI Authorized protective services PINS diversion Authorized preventive services Homelessness/minor living on own/abandonmefBL Domestic violence " Fire/other disaster/other emergency (specify). below for TANF-EA F eligibilily: ices^tizensof the U.S. or qualified immigranis as defined the following circumstance(s):

B. TANF-EAF REQUIREMENTS. Applicant(s) must

I.

CITIZENSHIP. Are all children who are applying for'

under the federal PRWORA?

B* YES D NO (Family ineligible for any funding) ""If no...go to Section IV, Eligibility Summary. AGE. Was any_member of the family under the age of 18, or under the age of 19 and attending secondary school (high school) or an equivalent level of vocation or technical training or did the case include a pregnant woman of any age? 1 YES D NO (Family ineligible for TANF-EAF and Title XX Below 200%) -If no... go to Section IV, Eligibility Summary. LIVING WITH A SPECIFIED RELATIVE. Was the child living in the home of a specified relative alany lime within six months before the application for services, or did the case include a pregnant woman of any age? $ YES D NO (Family ineligible for TANF-EAF) -If no...go to Section III, Title XX Be|ow 200%. NO PREVIOUS EAF AUTHORIZATION. Was there no EAF authorization written in the past 12 inonlhs, except one written in the past 30 days, or one written for the same emergency where the authorization has not been closed? ^ YES D NO (Family ineligible for TANF-EAF) "If no...go to Section III, Title XX Below 2 0 0 % . . INSUFFICIENT RESOURCES. Is at least one member of the family in receipt of public assistance or SSI? <| YES fj'NO (Family ineligible for TANF-EAF) <^lf no...go to Section III, Title XX Below 200%. NEED FOR SERVICES DUE TO REASONS OTHER THAN REFUSAL OF EMPLOYMENT/TRAINING. Did ihe family's need for services arise for reasons other than the parent/specified relative's refusal without ood cause to accept employment o r training? . . ' - . . - . ' . 1 YES D NO (Family ineligible for TANF-EAF) "If no...go to Section III, Title XX Below 200 %. NEED FOR SERVICES DUE TO REASONS OTHER THAN MISMANAGEMENT OF A PA GRANT. Did the family's need for services arise for reasons other ihan the parent/specified relative's mismanagement of a public assistance grant? SjYES D NO (Family ineligible for TANF-EAF) "-irno...go to Section III, Title XX Below 200%.

3.

4.

5. 6.

7.

r If answers lo Part B, 1-7 are "YES," sign below and go to Section III. n accordance with 18 NYCRR 372.4(d), costs for services that are necessary to address needs arising from the cited mergency are authorized under the EAF program. This authoyfzationw^l continue until the emergency ends. Worker's Signature, upervisor's Signature.

.DSS-4811 (REV.

B/04)

amily Eligibility Checklist, Page 2 pi 4

SECTION III. Title XX Below 200% ELIGIBILITY AUTOMATIC ELIGIBILITY. Are all children in ihe child welfare case who are applying for or receiving services in receipt of public assistance (Family Assistance, Safely Net), Medicaid, Food Stamps, Supplemental Security Income (SSI) or HEAP? D YES (Case eligible for Title XX Below 200%) Ifyes...go to Section IV, Eligibility Summary. 0f NO "" If no, answer Ihe questions below.

CERTIFYING TITLE XX BELOW 200% ELIGIBILITY. APPLICANT(S) MUST MEET ALL REQUIREMENTS BELOW FOR TITLE XX BELOW 200% ELIGIBILITY: 1. CITIZENSHIP. Is at least one child who is applying for or in receipt of services a US. citizen or qualified immigrant as defined under the federal PRWORA? D YES D NO (Case ineligible for any funding) ^If no...go to Section IV, Eligibility Summary. MINOR CHILD, PREGNANT WOMAN, OR NON-CUSTODIAL PARENT. Docs the family include: (a)a child under the age of 18, or under the age of 19 and attending secondary school (high school) or an equivalent level of vocational or technical training, regardless of living arrangement; or (b) a pregnant woman; or (c) a non-custodial parent? DYES D NO (Family ineligible for Title XX Below 200%) ^lfno...go to Section FV, Eligibility Summary. FAMILY INCOME. Is the combined gross income of all ihe family members below ihe 200% of poverty income level? Calculation of Gross Income convert all income to annual income. Name
1.. 2.. 3.. 4.. 5..

2.

3.

Relationship

Weekly Income Calculation

Monthly Income Calculation

Annual Income

$ S S S S

/wk x 52 = S /wk x 52 = S /wk x 52 = $ /wk x 52 = S /wk x 52 = $

S S S $ S

/mo x 12 = 5 /mo x 12 = !5 /mo x 12 = !> /mo x 12 = 3> /mox12 = S

S I S S S

/vr /yr /yr /yr /yr

Include only countable income. a. Total gross income is: b. Subtract child support payments made c. Net gross income Tor 200% test is d. Total family size is

"$ $ $

per year.
per year per year.

Time period must be Ihe same for a, b, and c.

Compare combined gross income (item c) to the 200% of poverty income standard for the applicant's family size (item d) to determine if income is less than Ihe 200% of poverty standard. , .' .

D YES Income test is met based on calculation of combined gross income of applicant's family members based on applicant family size. " . D NO (Family ineligible for Title XX Below 200%) -Jf no...go to Section IV, Eligibility Summary.
"If answers are "yes" to Questions 1-3, go to Section IV, Eligibility Summary.

(REV. 8/04)

Family Eligibility Checklist, Page 3 of 4

SECTION IV. ELIGIBILITY SUMMARY & SIGNATURES/SUPERVISOR'S REVIEW

Eligibility Results: THE FAMILY IS:

ELIGIBLE FOR TANF-EAF AND TITLE XX BELOW 200%: D Encode family 04 (eligibilily code) and add"D" suffix for preventive services and "C suffix for any non-prevenlive services (direct service and POS lines) as needed on WMS. ELIGIBLE FOR TANF-EAF ONLY: D Encode family 04 (eligibilily code) on WMS. ELIGIBLE FOR TITLEXX BELOW 200% ONLY: D Encode the case with any appropriale code other lhan04, and add "D" suffix for preventive services and "C' suffix for any non-preventive services (direct service and POS lines) as needed on WMS. INELIGIBLE FOR TANF-EAF AND TITLE XX BELOW 200% (eligible for Title XX): Opcode family 14 (eligibilily code) on WMS. . INELIGIBLE FOR ANY FUNDING [Costs for this case are not reimbursable by any federal or State funding (except for certain emergency services - see Manual) as no family member is a U.S. citizen or qualified immigrant.}: D Encode family 14 (eligibilily code) and add "N" suffix to direct service and POS lines as needed on WMS. Worker's Signature. Supervisor's Signature SECTION V. DOCUMENTATION OF ELIGIBILITY Indicate the documentation used for each item of eligibility. Indicate where that documentation is located in the case record or that it is attached to this form. (ForTiile XX Below 200%, see the footnote at the end of this section.) Item 1. Emergency Situation (TANF-EAF) Documentation Location in Case Record Attached

2.

Citizenship
(All Funding Sources)

\j /?
3. Age
(TANF-EAF/TiileXX Below 200%)

4.

Living With a Specified Relative (TANF-EAF)

/ e7Jf dt 5. No Previous EAF Funding {TANF-EAF)

6.

Insufficient Resources (TANF-EAF)

DSS-4811 (REV. 8/04)

-amily Eligibility Checklist, Page 4 of 4

7.

Need Due to Reasons Other Than Refusal of Employment/Training (TANF-EAF)

r*
}. Need Due to Reasons Other Than Mismanagement of PA Grant (TANF-EAF)

,,,J MD

I.

Member of Family on FA, SN, MA, Food Stamps, HEAP, SSI or income below 200%
(TiileXX Below 200%)*

/fthh

0. Minor Child, Pregnant Woman, or Non-Custodial Parent (Title XX Below 200*)*

FftSP;

<"*

For the Title XX Below 200% program, all items of eligibility except for qualified immigration status can be documenled by the client's attestation. The signed Application for Services Form (LDSS-2921), the WMS Clearance Report, and this Checklist are sufficient documentation for Title XX Below 200%. However, the worker may request verification of any item.

LOSS 4779 (Rev 5/04)

APPROVAL OF \
N

APPLICATION FOR CHILD C>

SUFFOLK COUNTY DSS CHILD CARE UNIT

i BENEFITS

DA'T| October 13, 2009 S00900898 CIN NUMBER S00900898

CASE NAME (And C/O Name if Present) AND ADDRESS

NAME AND ADDRESS OF AGENCY/CENTER OR DISTRICT OFFICE

CASE NUMBER

P.O. BOX 18100

HAUPPAUGE, NEW YORK 11788
GENERAL TELEPHONE NO. FOR QUESTIONS OR HELP OR Agency Conference Fair Hearing information and assistance Record Access (631) 853-3632

Palmiotti, Winona

XXX

(631)853-3642 (800) 342-3334 (631)853-3632 (631) 232-2400

Legal Assistance information

OFFICE NO. UNIT NO.
MSU

WORKER NO.
118

UNIT OR WORKER NAME

TELEPHONE NO.

(631)854-9453

Wong, Armfield

Your application for child care benefits has been accepted. Your child care benefits are effective September 29, 2009 to March 01. 2010, while you are Referred for protective services. Payment will be provided on behalf of the following: Child(ren)
Piscitelli, Winona

For this provider

4

For the amount of:*

Full or Part Time

Full Time

'Payment may vary based on fluctuations in your approved activity and/or absences.

Benefits will be paid:

() Directly to you. (X ) Directly to your provider. Your provider must submit a monthly bill and attendance sheet. In order to continue to receive benefits these are your responsibilities:
Notify your caseworker immediately of any change in family income, who lives in your house, employment, child care arrangements or other changes which may affect your continued eligibility or the amount of your benefit. Promptly pay any family share required. You must actively pursue a child support order and modifications as required, unless you have a good cause exception.

YOU HAVE THE RIGHT TO APPEAL THIS DECISION. BE SURE TO READ THE BACK OF THIS NOTICE ON HOW TO APPEAL THIS DECISION
CLIENT/FAIR HEARINGS COPY

Suffolk County Department of Social Services

CHILD CARE BUREAU LETTER OF APPROVAL

Date: Client: Case Number: Parent Fee: 10/13/2009 Winona Palmiotti S00900898

This is to inform you that certified day care has been authorized for the days and hours you are actively employed. Care is authorized for the children and respective authorized periods listed below. Payment to the provider will only be for authorized care, and the provider is responsible for the collection of the parent fee noted above. Child(ren)'s Name Winona Piscitelli Purchase of Service Period From 09/29/2009 To 02/28/2010

The client (guardian), Winona Palmiotti has agreed to pay the parent fee (noted above) per week in advance. This weekly client fee shall not be prorated should the child(ren) be absent from day care part of the week and shall not be waived should the child(ren) be absent the full week. Failure to pay the parent fee will lead to termination of day care services. CLIENT RESPONSIBLITIES: Client is to inform the day care worker PROMPTLY of any changes in employment, income, marital status, living arrangements, or address. Client is responsible to arrange for an emergency child care source for those days the provider is unavailable. If you have any questions, please contact your case worker. PROVIDER RESPONSIBILITIES: Provider will submit to Services Accounting each month the total daily hours of care provided (to the closest 1/2 hour) for each authorized child. Submission of inaccurate attendance records may result in the removal of your DSS placements and/or revocation of your license. You are required to report within two working days, by telephone, to the Department, any absences in excess of five consecutive days. Special Client/Provider Instructions: FT.

A copy of this letter has been sent to: Winona Palmiotti

XXX Shirley, NY 11967

Very truly yours,

Examiner Supervisor

Examiner

853y

KEEP THIS LETTER FOR YOUR RECORDS

CSA-045 E S (Rev. 9/07)

Printed by KinderTrack

LOSS 4779 (Rev.5/04) Reverse

^,

x_^

RIGHT TO REJECT SERVICES: Approval of your application does not obligate you to accept the services. decline to accept services if you choose to do so.

You may

RIGHT TO A CONFERENCE: You may have a conference to review these actions. If you want a conference, you should ask for one as soon as possible. At the conference, if we discover that we made a wrong decision or if, because of information you provide, we determine to change our decision, we will take corrective action and give you a new notice. You may ask for a conference by calling us at the number on the first page of this notice or by sending a written request to us at the address listed at the top of the first page of this notice. This number is used only for asking for a conference. It is not the way you request a fair hearing. If you ask for a conference you are still entitled to a fair hearing. Even if you ask for a conference, you still have only 60 days from the date of this notice to request a fair hearing. Read below for fair hearing information. RIGHT TO A FAIR HEARING: If you believe that the above action is wrong, you may request a State fair hearing by: (1) Telephoning: (PLEASE HAVE THIS NOTICE WITH YOU WHEN YOU CALL) 800-342-3334

OR (2) Writing: Complete the information, sign and mail to the New York State Office of Administrative Hearings, Office of Temporary and Disability Assistance, P.O. Box 1930, Albany, New York 12201-1930. Please keep a copy for yourself. OR (3) FAX: Your fair hearing request to (518) 473-6735 OR (4) Email: Your fair hearing request to http://www.otda.state.nv.us/oah/forms.asp
I want a fair hearing. The Agency's action is wrong because:

Signature of Client:

Date:.

YOU HAVE 60 DAYS FROM THE DATE OF THIS NOTICE TO REQUEST A FAIR HEARING If you request a fair hearing, the State will send you a notice informing you of the time and place of the hearing. You have the right to be represented by legal counsel, a relative, a friend or other person, or to represent yourself. At the hearing you, your attorney or other representative will have the opportunity to present written and oral evidence to demonstrate why the action should not be taken, as well as an opportunity to question any persons who appear at the hearing. Also, you have a right to bring witnesses to speak in your favor. You should bring to the hearing any documents such as this notice, pay stubs, receipts, child care bills, medical verification, letters, etc. that may be helpful in presenting your case. LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under "Lawyers" or by calling the number indicated on the first page of this notice. ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: To help you get ready for the hearing, you have a right to look at your case file. If you call or write to us, we will provide you with free copies of the documents from your file which we will give to the hearing officer at the fair hearing. To ask for documents or to find out how to look at your file, call us at the Record Access telephone number listed at the top of page 1 of this notice or write us at the address printed at the top of page 1 of this notice. Also, if you call or write to us, we will provide you with free copies of other documents from your file which you may need to prepare for your fair hearing. If you want copies of documents from your case file, you should ask for them ahead of time. They will be provided to you within a reasonable time before the date of the hearing. Documents will be mailed to you only if you specifically ask that they be mailed. INFORMATION: If you want more information about your case, how to ask for a fair hearing, how to see your file, or how to get additional copies of documents, call us at the telephone numbers listed at the top of page 1 of this notice or write to us at the address printed at the top of page 1 of this notice.

LDSS-2921 Statewide (Rev. 1/05)

I DOES THIS PERSON j (INCLUDING YOUR MINOR

LDS

M3
_O

' CHILDREN) BUY FOOD I OR PREPARE MEALS

j Wl TH YOU-? HIGHEST SCHOOL GRADE COMPLETED

RSELF QM THIS FIRST LINE. PLEASE PRINT.

die Initial) THIS PERSON IS APPLYING FOR:
LAST NAME DATE OF BIRTH EMRG Month i <5py | "^
RELA

-1

SOCIAL SECURITY NUMBER OF APPLYING MEMBERS

Se9 How to Com

rii

M.I. !

TA

FS

MA

MSP

CG

FC

- D a y - ( Year I , P

TO . TO YOU

i ^ P'ete" "istrucfion book i i i_ ' tPub-i 301 Statewide, or talk to your worker)] v fYESlTJo"

&i

.aljfcii 0 S

f j" i

l/J i n G n
"

i' I !

I I
i
i"

icl ^YVLottl PtSCcbeLU P*scc4lli VSs/

TjcTTosI JE_ dc

u ~7 ^73 ^ P

Sl

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i_l JL,
1
L

_02

_04

I i
,, __L_
I' in = Mo ti '

_gs _oe
_07

f\> if>

one
UNO

FIRST NAME

M.I.

-AST NAME

!'

DO WOT WRITE IN SHADED AREAS

" uci;
OUR

I
'me i j
FIRST NAME
U

08

^
IF YES, WHO

M.I.

LAST NAME LINE

REASON

''ilD WE

1 >

i~

CONTRIBUTION/ DEEMED INCOME

j i

CHECK IF MEMBER OF FS HOUSEHOLD

;) [

IMMIGRATIOM STATUS

j !

STATUS ADJUSTED

jjill
j (

NO

DATE OF ENTRY/STATUS MONTH DAY j YEAR

APPLIED FOR CITIZENSHIP YES J NO

SPONSORED JfES

j LN

DEGREE RECEIVED

IN |

DbGH

NO .~~~~~.

joi
. j 02
...

OS _, .

08 j 07 . 08

~ | 03

"j " ~ ""

j.,,lmm,_

._-,_ ._j 04

1/05)

PAGES
-""^ "="S''-''gi3reagvB5:g:

RACE/ETHNIC AFFILIATION CODES !! ! A B P W U Hispanic or Latino Native American or Alaskan Naiive Asian Black or African American Native Hawaiian or Pacific Islander White Unknown (MA Only) ENTER Y (YES) OR N (NO) IF HISPANIC OR LATINO ENTER Y (YES) OR N (NO) FOR EACH RACE AFFILIATION

ENTER APPROPRIATE CODES

ANTICIPATED F(JTURE_ACTION
DATE

RELATED CASE NUMBERS

Relationship Filing Unit

SERVICE 5UGIS3IUTY PROCESS CODE i

Legally Responsible Relative Single Economic Unit I-S Household Composition / FS Aged/Disabled Individual 1 / Photo ID/APIS
Multi-Suffix/Co-op Case Notice (Single Economic Unit Questionnaire)

RFi/OCA

/ Health Snsuratnce

PAGE 16 _ __.

LOSS-2S21 Statewide (Rev. 1/05

STANDARD UTILITY ALLOWANCE (SUA) - I understand that Temporary Assistance (TA) and Food .Stamp Benefits (FS) recipients are categorically income eligible for the Home Energy Assistance Programs (HEAP). If I am not included in the annual automatic HEAP payment process for certain TA and FS recipients, I intend to apply for a HEAP benefit within the next 12 months, i f ! decide not to apply for HEAP within the next 12 months, i will let my worker know. I understand that FS recipients are eligible for a telephone allowance if they pay for a home phone, cell phone, phone calling card or coin-operated pay phone. If I do not have to pay for phone calls, I will let my worker know. AS81GWMEMT OF SUPPORT' RIGHTS i assign to the State and social services district any rights I have to support from persons having legal responsibility for my support and any rights ! have to support on behalf of any family member. .1 _ RELEASE OF EDUCATIONAL of Health arid local department of social sef give permission to the State Department

L1FELSME - For applicants/recipients of temporary assistance and/or food stamp benefits: The Office of Temporary and Disability Assistance may or may not release your name and address to your telephone service provider. Your telephone service provider may or may not use this information to enroll you in their Lifeline Service for a discounted telephone rate. if you do no* want this 'mlomtatton released!; check this box l~l. You may contact your telephone service provider directly for enrollment in the discounted rate Lifeline Service. Wfedicaid-only applicants/recipients must contact their telephone service provider directly for enrollment in the discounted rate Lifeline Service. FOR REIMBURSEMENTS" OF PUBLIC ASSISTANCE BENEFIT0, PAYMENT - 1 authorize the Commissioner of the Soc Security Administration (SSA) to send to the local social services district the amount due" to me at the time of my first payment of (1) retroactive Supplemental Security Income (SSI) benefits that I may receive upon an application for SSi or (2) retroactive SSI benefits I may receive if I am terminated or suspended from receiving SSI benefits and am later reinstated. I understand that the local social services district may take from my SSI payment the amount of Public Assistance (except assistance paid wholly or partly with federal funds) that was paid to rne during the period beginning with my first day of eligibility for SSI or the first day to which SSi benefits were reinstated after a period of suspension or termination and ending with the month that SS! payments actually began (or the following month if the local social services district cannot stop delivery of my last public assistance payment during the month that SS! payments began). After taking this money from my SSI check(s), the local social services district will pay me the balance; if there is any, no later than 10 working days from the date it receives my SSi payment. ! also understand that if the district takes more money than I believe was paid to me as Public Assistance, i wil! be given an opportunity for a hearing. i understand that: ^ ^=n o the SSA may treat the date that ! subny^this^ signed authorization to the lot. ... social services district as the date i firsrb&come eligible for SSI if I submit an application for initial SSi benefits within the next 80 days. this authorization wili apply to any SSI application or appeal which is presently pending before the SSA with respect to me and to any SSI application I make or appeal i request with respect to the period ending one year after I sign this agreement. This authorization will terminate one (1) year after it is received by the local social services district and wil! not have any effect upon future SSi applications, appeals or reviews if my case is completely decided, if the SSA makes an initial payment of SSI either on my application or after a period of suspension or termination or if the State and I mutually agree to terminate the authorization.

Obtain any information regarding the c^p'^nai records of myself and/or my minor child(ren), herein named, including information necessary for claiming MA reimbursement for health-related educational services. o Provide the appropriate federal government agency access to this information for the sole purpose of audit. RELEASE OF ^FORMATION FOR THE EARLY INTERVENTION PROGRAM - If my child is evaluated for or participates in the New York State Early Intervention Program, I give permission to the local Department of Social Services and New York State to share my child's Medical Assistance eligibility information with my county or municipal Early Intervention Program for the purpose of billing Medical Assistance. RELEASE OF MEDICAL INFORMATION - i consent to the release of any medical information about me and any members of my family for whom I can give consent: by my Primary Care Provider, any other health care provider or the New York State Department of Health (SDOH) to my health plan and any health care providers involved in caring for me or my family, as reasonably necessary for my health plan or my providers to carry out treatment, payment, or health care operations; by my health plan and any health care providers to SDOH and other authorized federal, state, and local agencies for purposes of administration of the Medicaid, Child Health Plus and Family Health Plus programs; and, by my health plan to other persons or organizations, as reasonably necessary for my health plan to carry out treatment, payment, or health care operations. I also agree that the information released may include HIV/, mental health or alcohol and substance abuse information about me and members of my family, to the extent permitted by law. if more than one adult in the family is joining a Family Health Plus or Medicaid health plan, the signature of each adult applying is necessary for consent to release information.

I have read and understand the notices above, i understand and agree to the assignments, authorizations and of psrjury that the information i have given or will gave to the local social services district is correct.
APPLICANT/REPRESENTATIVE SIGNATURE DATE SIGNED

above, ! svg

under the penalties

SBAND/WIFE OR. PROTECTIVE REPRESENTATIVE SIGNATURE

Enter S00#
_^..,,,~,.^,,

Status

CID
j

Close Date

-For Selected Individual

Minimize f MI! Individuals <"" Correction r Selected Individual j f Reassignment Wkrr~ Start:
End:

Court Ordered Individual

Placement
ID

SD:

Close Case ICPC

Plan Complete f~~

Archive
546376

Save

Cancel Last Name IPALMIOTTI !PISCITELLI PISCITELLI

Hm A B fA

First Name ;WINONA 'PAUL WINONA

Individuals for Selected SOO Case DOB CIN SEX|Eth |Service|5CR ; 04/07/73 BV16784F ;F ;CWPROT 1 j 05/27/72FEK99451E | M !CW FpROT ;"j [07/06/05 DW78162EJF [cwiFC [1

|Tm |Wkr[Role [End ; 063 102 P j 063; 102;P \ 063!" 102IP

Search/Add New Address Hm House* Street 915i SUNRISE HVvY 318; ELLISON AVE

Search/Add New Individual 7Co7r7piiex"Name ]Apt# POBox Town WESTBABYLC:NY WESTBURY TNY 11704 11590

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| Housef] Street

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SOO Case: 900898 A 10/13/2009 Hm A B fA First Name WINONA PAUL WINONA Addresses: A 915 SUNRISE HWY ROOM 116 WEST BABYLON NY 11704 77369 B 318 ELLISON AVE WESTBURY NY 11590 52398 Foster Addresses: Ml M Last Name PALMIOTTI PISCITELLI PISCITELLI
DOB CIN SEX Eth

04/07/73 05/27/72 07/06/05

BV16784FF EK99451EM DW78162F

CW CW CW

10/09/09

FRI 09:20 FAX 6318543358

CPS MACARTHUR PARK ********************* *** TX REPORT *** *********************

1^001

TRANSMISSION OK TX/RX NO CONNECTION TEL CONNECTION ID ST. TIME USAGE T PCS. SENT RESULT
1361

22688
10/09 09:19 01'06 3 OK

COUNTY OF SUITOLK

STEVE LEVY SUFFOLK COUNTY EXECUTIVE

DEPARTMENT OF SOCIAL SERVICES

Gregory J. Blass

Commissioner

To:

From: Lisa Scafic 3 631-854-9139

Phone:
Re:

CC:
Q For Review D Please Comment D Please teply D Please Recycle

djJMrgent

Comments:

m: Lisa Scafide 631-854-9139

Pages: Phone:
Date:
CCi
/ Q g-~ Q

*
a Urgent D IFor Review

D Please Comment

D Please Reply

D Please Recycle

Comments:

e,r

Thank you for your prompt atten on to this matter Sincerely *^

LisaScafide Team 63/102 Confidentiality Notice; The d information which is confidential person or entity named above, that any disclosure, copying dis information is strictly prohibited E icuments, which accompany this telefax transmission sheet, contain and/or legally privileged, and which is intended only for the use of the f you have received this transmission in error you are hereby notified ibution, or the taking of any action in reliance of the contents of this id that the documents must be returned to this office immediately.

If you have received this transm 5sion in error, or if any parts of it are missing or illegible, please notify JUS at 631-854-8139

BOX 18100

HAUPPADGE, N.Y. 11788 - 8900

(631)854-9935

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have violated its terms and to bring him or her efore the court to face penalties authorized by law, Federal law requires that this order i iust be honored and enforced by state and tribal courts, including courts of a state, the District of Columbia, a commonwealth, ten toiy or possession of the United States, if the person against whom the order is sought is an intimate partner of the protected pi rty and has or will be afforded reasonable notice and opportunity to be heard in accordance with stare law sufficient to protect t lat person's rights (18 U.S.C. 2265.. 2266). It is a federal offense to: cross state ines to violate an order of protection; cross state lines to engage in stalking, harassment or domestic violence against an inti oate partner or family member; possess, purchase, ship, transfer or receive a handgun, rifle, shotgun, or other .firearm or arm uinition following a conviction of a domestic violence misdemeanor involving the use or attempted u$e of physical force or a dear .y weapon; or (except for military or law enforcement officers while on duty) possess, purchase, ship, transfer or receive a ha idgun, rifle, shotgun or other firearm or ammunition while an order of protection, issued after nonce and an opportunity to be hea d, that protects an intimate partner against assault, harassment, threatening and/or stalking, remains in effect (18 U.S.C. 922(g 8), 922(g)(9), 2261, 2261A, 2262). PURSUANT TO SECTION 1113 OF THE F VMILY COURT ACT, AN APPEAI. FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE O IDER BY APPELLANT IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLAN T BY THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE LAW GUARDIAN UPON' 'HE APPELLANT, WHICHEVER IS EARLIEST.

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SUFFOLK COUNTY DEPARTMENT OF SOCIAL SERVICES FCSA FACE SHEET xffil New D Update
DATE: 10-9-09 CASE NAME(s): Palmiotti, Winona SCR#: 24158873 S00#: ADDRESS: 1355 Locust Ave Bohemia WORKER: 102 UNIT: 63 PHONE: HOME*: 516 238-0371 WORK #: CID (Case Initiation Date): 9-16-09 PRIMARY LANGUAGE: english NATIVE AMERICAN TRIBE: MOTHER OR SIGNIFICANT OTHER SPOUSE OR SIGNIFICANT OTHER Legal Name: Palmiotti, Winona Mae DOB: 4-7-73 Place: Legal Name: DOB: Place: Citizen: Citizen: (Last, First, Middle) (Last, First, Middle) AKA: Winona Grant, Winona Marzocco AKA: Tel. (Home): 516 238-0371 Educ. Level: Office: Office: Tel. (Home): Educ. Level: employer: self Employer: Occupation: truck driver Occupation: (Name and address) (Name and address) SS#: 067703251 Income: 0 Marital Status: unk SS#: Income: Marital Status: Emergency Contact: Name: Address: Tel. (Home): Office: Relationship: FATHERS (LEGAL/PUTATIVE/ALLEGED/ADJUDICATED) Name Paternity Status Address DOB Place of Birth Race/Religion SSN Child's Name Paul Piscitelli Putative 318 Ellison Ave Westbury 5-27-72 Italy white 051604668 Winona Piscitelli

Name

Relationship to client

DOB

OTHER MEMBERS OF THE HOUSEHOLD Sex Place of birth

Race

Religion

Name

Relationship to Client

DOB

(NON RESIDENT) OTHER FAMILY MEMBERS Place of Birth Race

Religion

Religion

Residence or Location

Page I

SUFFOLK COUNTY DEPARTMENT OF SOCIAL SERVICES FCSA FACE SHEET xffil New D Update
DATE: 10-9-09 CASE NAME(s): Palmiotti, Winona SCR#: 24158873 S00#: ADDRESS: 1355 Locust Ave Bohemia WORKER: 102 UNIT: 63 PHONE: HOME*: 516 238-0371 WORK #: CID (Case Initiation Date): 9-16-09 PRIMARY LANGUAGE: english NATIVE AMERICAN TRIBE: MOTHER OR SIGNIFICANT OTHER SPOUSE OR SIGNIFICANT OTHER Legal Name: Palmiotti, Winona Mae DOB: 4-7-73 Place: Legal Name: DOB: Place: Citizen: Citizen: (Last, First, Middle) (Last, First, Middle) AKA: Winona Grant, Winona Marzocco AKA: Tel. (Home): 516 238-0371 Educ. Level: Office: Office: Tel. (Home): Educ. Level: employer: self Employer: Occupation: truck driver Occupation: (Name and address) (Name and address) SS#: 067703251 Income: 0 Marital Status: unk SS#: Income: Marital Status: Emergency Contact: Name: Address: Tel. (Home): Office: Relationship: FATHERS (LEGAL/PUTATIVE/ALLEGED/ADJUDICATED) Name Paternity Status Address DOB Place of Birth Race/Religion SSN Child's Name Paul Piscitelli Putative 318 Ellison Ave Westbury 5-27-72 Italy white 051604668 Winona Piscitelli

Name

Relationship to client

DOB

OTHER MEMBERS OF THE HOUSEHOLD Sex Place of birth

Race

Religion

Name

Relationship to Client

DOB

(NON RESIDENT) OTHER FAMILY MEMBERS Place of Birth Race

Religion

Religion

Residence or Location

Page I

Name of Agency: Contact Person: Telephone Number: Name of Agency: Contact Person: Telephone Number: Child: Child: Child: Child:
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OTHER SOURCES INVOLVED WITH FAMILY Name of Agency: Contact Person: Telephone Number: Name of Agency: Contact Person: Telephone Number: Child Ancillary worker/unit: Ancillary worker/unit: Child: Ancillary worker/unit: Child: Ancillary worker/unit: Child: LEGAL INFORMATION Type of order/Court orders: removal/family Docket Number: : nn1 6863-09 Type of order/Court orders: order of protection/family Docket Number: : nn1 6863-09 Type of order/Court orders: Docket Number. Type of order/Court orders: Docket Number: Docket Number: Type of order/Court orders: Type of order/Court orders: Docket Number: Type of order/Court orders: Docket Number: FOSTER CARE PLACEMENT/OTHER OUT OF HOME (N-Docket, V-Docket or D-Docket) Type of Placement Placement Date Caretaker's Name Address Ancillary worker/unit: Ancillary worker/unit: Ancillary worker/unit: Ancillary worker/unit:

Chi Child's name: Winona Piscitelli ) Child's name: Chi! Child's name: Child's name: Child's name: Child's name: Child's name:
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