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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406212542
Report Date: 08/31/2021
Date Signed: 08/31/2021 04:13:56 PM

Document Has Been Signed on 08/31/2021 04:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:GUTIERREZ FAMILY CHILD CAREFACILITY NUMBER:
406212542
ADMINISTRATOR:MARIA GUTIERREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 975-5570
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:56 PM
MET WITH:Maria GutierrezTIME COMPLETED:
04:25 PM
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On 8/31/2021 at 2:56pm, Licensing Program Analyst (LPA) Melissa Stewart conducted a Facility Risk Assessment for COVID19 with Licensee, Maria Gutierrez and adult Assistant who provided translation in Spanish. All answers indicated no exposure to COVID19. The purpose of the visit, Required 1 year inspection, was explained. Licensee, Assistant and children over two (2) years who were not eating, wore a face covering. LPA observed the required documents posted inside of the home on the wall adjacent to the front door. There were four (4) children and one (1) infant present at time of inspection. Licensee accompanied LPA on a tour of the home inside and out. Child care services are provided in the the living room and dining room. LPA observed age appropriate toys, books and child sized tables and chairs. The bathroom used by children was observed to be clean and free of toxins. There is a half door which makes the kitchen inaccessible to children in care. There are four (4) bedrooms passed the kitchen. Licensee reported that the older children occasionally use the first bedroom and the remaining bedrooms are kept locked. Licensee has a portable crib and infant swing in her bedroom. Licensee reported that she or her Assistants are always in the bedroom with the sleeping infant and that the infant is removed from the swing when sleeping.

Licensee stated there are no guns or ammunition in the home. Detergents, cleaning compounds, medications and other items such as kitchen knives which could pose a danger to children are stored inaccessible to children. Smoke and Carbon monoxide detectors were tested at 2:59pm and found to be operational. LPA observed the 2 A10 BC fire extinguisher with a receipt of purchase date of 8/30/2020 and a 3A 40 BC fire extinguisher with receipt of purchase date 8/7/2021. Licensee completes and documents emergency drills. The most recent drill was held on 8/18/21.

LPA observed the outdoor activity area which is accessed through french doors in the dining room. There is a swing set and play house located on artificial grass. The backyard is fully fenced. There is a granny flat beyond the fence to the right and a storage area beyond the back fence. There is also an activity area in front of the home which is enclosed by a 2-3 foot fence. Continued on 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Melissa K Stewart
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GUTIERREZ FAMILY CHILD CARE
FACILITY NUMBER: 406212542
VISIT DATE: 08/31/2021
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Licensee stated that she or her Assistants always supervise children in this activity area. LPA observed play house, climber and shade tree.

Licensee has current Pediatric CPR and first aid expiring on 7/17/2023. Licensee and Assistants have met SB 792 immunization requirement. Mandated Reporter Training per AB 1207 has not been completed. LPA advised that the training is now available in Spanish at www.mandatedreporterca.com. Licensee stated that she and Assistants will complete the AB1207 training and submit a copy of completion certificate to LPA on or before 9/10/2021. Facility roster and a sample of children's records were reviewed and found complete.



Infant Safe Sleep Regulation section 102425 was discussed. LPA provided PIN 20-24-CCP and Individual Infant Sleep Plan (LIC9227) in Spanish. LPA also provided a sample Infant Sleep Log for 15 minute checks of all children under the age of two (2) years. LPA provided a copy of the “Effects of Lead Exposure” brochure in Spanish and in English to be distributed to all families at time of enrollment. LPA advised Licensee that Title 22, Division 12 regulations for Family Child Care Homes and California Department of Public Health COVID-19 guidelines for child care programs can be accessed on-line at www.cdss.ca.gov. LPA provided information on how to subscribe to receive Provider Information Notices (PINs) from Community Care Licensing Division via email.

Incidental Medical Services (IMS) policy was discussed. Licensee stated that there are no children enrolled who require medications at this time. 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: www.ada.gov/childqanda.htm

In the areas evaluated today, no deficiencies were cited.

A copy of this report and appeal rights were discussed and left with Licensee, Maria Gutierrez, whose signature on this form confirm receipt of these documents. Report was read in English and Assistant provided Spanish translation.

LPA provided a Notice of Site Visit (LIC 9213) to be posted. FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Melissa K Stewart
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC809 (FAS) - (06/04)
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