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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494951
Report Date: 04/22/2022
Date Signed: 04/22/2022 03:26:44 PM


Document Has Been Signed on 04/22/2022 03:26 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:GUTIERREZ FAMILY CHILD CAREFACILITY NUMBER:
197494951
ADMINISTRATOR:LISSET GUTIERREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 774-9979
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:14CENSUS: 0DATE:
04/22/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Lisset GutierrezTIME COMPLETED:
03:38 PM
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Licensing Program Analyst (LPA), Keyona Scott, conducted an announced Pre-licensing inspection on 04/22/2022. LPA met with Applicant, Lisset Gutierrez, at 9:40 AM and was guided on a tour inside and outside of the home.

Present during today’s inspection was Applicant and Applicant’s spouse. Adults residing in the home include Applicant and Applicant’s spouse. All Adults present, residing, working and/or volunteering in the home have a criminal record clearance or exemption. The LIC279B (Children In Your Home) is on file at the El Segundo Child Care Regional Office.

Applicant has applied to provide care for children ages 18 months to five (5) years of age. Upon licensure, Applicant will be granted the capacity to care for up to 12 children at a time; no more than four infants and eight children; until Landlord Consent (LIC 9149) is received. Child Care operation hours are scheduled for Monday through Friday, 7:00 AM to 6:00 PM. Per Applicant, children will be provided two meals (breakfast and lunch) and a snack while in care. LPA advised Applicant, if meals and/or snacks are brought from the child(ren)’s home, the container(s) shall be labeled with child(ren)’s name and properly stored or refrigerated.

All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a two-story dwelling that consists of three bedrooms, two bathrooms, family room, living room, dining room, office, kitchen, hallway closet, laundry area and detached garage. Per Applicant, no childcare will be conducted in the detached garage. Off limit areas of the home are the entire second level of the home and living room #2. The second floor of the home is made inaccessible by safety gate at the bottom stairwell entrance. All bedrooms are located on the upper floor of the home in which all bedroom and bathroom doors on the second floor will remain closed during operation hours. Applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

Page 1
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GUTIERREZ FAMILY CHILD CARE
FACILITY NUMBER: 197494951
VISIT DATE: 04/22/2022
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Per Applicant, childcare will be conducted in the main classrooms, located in the family room and divided living room of the home. Parents will drop off and pick up child(ren) at the front door entrance of the home in main classroom 1. Health screenings will be conducted daily at the front entrance prior to parents leaving and the child(ren) entering the home. LPA observed the following age-appropriate toys in the main classroom 1: cubby storage cabinet, table and chair sets, playset, bookshelf with books and plenty of age appropriate toys. The living room located through the right of the main classroom or through the hallway to the right is divided into two rooms by dividers and a storage shelf. The entrance to the classroom 2 is through main classroom 1 to the right. Classroom 2 will be utilized for motor skill activities and sciences. The storage closet located adjacent to classroom 2 is used to store all activities and arts and crafts materials. Classroom 2 will also be used as a napping area. Applicant has napping cots available for use and plans to purchase napping mats. Children will utilize the dining room area when assisting with preparing meals and baking. The kitchen, located adjacent from the dining room, is made inaccessible by safety gate at the kitchen entrance. LPA observed safety locks and latches on lower cabinets and drawers in the kitchen. The laundry area is located, through the kitchen. The dryer is front load and the washer is top load. The washer is stationed on wheels which lock in place; therefore, Applicant can move washer to secure dryer from being opened. Children in care will utilize the bathroom through the hallway entrance to the left of main classroom 1. Per Applicant, children in care will be escorted to the bathroom as needed. LPA observed safety locks and latches on bathroom cabinets and shower. Living room #2, located through the hallway, to the right of main classroom 1, and across from the bathroom is off limit to children in care. There is a safety gate at the entry way of living room #2 to make inaccessible to children in care. LPA observed a fireplace in living room #2 that is not securely screened. Applicant agrees to place a secure screen on the fireplace to make inaccessible to children in care. Applicant will send video to LPA of securely screened fireplace.

(Page 2)
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GUTIERREZ FAMILY CHILD CARE
FACILITY NUMBER: 197494951
VISIT DATE: 04/22/2022
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The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Home has a working telephone. Hazardous materials in the kitchen and bathroom are inaccessible to children. All poisons are locked. The home utilizes a portable heater as a heating source and ceiling fan as a cooling source. Per Applicant, there is a or firearm in the home. Per Applicant, Applicant’s spouse and LPA’s observation, firearm is secured in a lockbox in off limit area of the home. Per Applicant’s spouse, there is no ammunition in the home. Applicant and Applicant’s spouse are aware if ammunition is present in the home, must be stored in a separate lockbox and different location from the firearm. Per Applicant, there is a pet hamster in the home that will be inaccessible to children in care during operation hours.

The home is equipped with at least one fully charged fire extinguisher which is at least a 2A:10:BC. The home is equipped with at least one working dual smoke and carbon monoxide detector. There is at least one first aid kit in the home. LPA received and reviewed current Pediatric CPR and First Aid certificates for Applicant with expiration date of 09/09/2023. Mandated Reporter training was completed on 12/02/2019. Applicant will renew Mandated Reporter training and email LPA the certificate of completion. Applicant completed Preventative Health and Safety training with one hour of Childhood Nutrition and Lead Exposure prevention on 11/08/2020. Family Child Care Home Orientation was completed by Applicant on 09/21/2021 and a copy of the certificate was provided to the Department. LPA obtained and reviewed copies of Applicant’s immunization record. Applicant agrees to obtain and provide proof of MMR immunization to LPA to place in Regional Office physical file. LPA has reviewed Applicant’s teaching verification and has verified Applicant meets the requirements for a Large Family Child Care Home.

Outdoor play will be conducted in the backyard to the west of the home. Children will enter the outdoor play area through classroom 2. The outdoor play area is fully fenced and free of dangerous and hazardous conditions. Applicant was advised that children shall always be physically and visually supervised. LPA observed age-appropriate toys in the outdoor play area. LPA observed a waterfall in the outdoor play area that has been covered with a table for children to conduct outdoor activities on. No pools, spas, hot tubs, fishponds, or similar bodies of waters observed on property.

Per Applicant, transportation service will not be provided. (Page 3)

SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GUTIERREZ FAMILY CHILD CARE
FACILITY NUMBER: 197494951
VISIT DATE: 04/22/2022
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While touring the home LPA did not observe the required form to be posted and provided Applicant with the following form to post:

· Notification of Parent’s Rights (PUB 394)



Applicant has submitted Emergency Disaster Plan to the Department and has on file in the home for review upon request.

Applicant was provided with Earthquake Preparedness Checklist (LIC 9148) to complete and place on file in the home for review upon request.

Applicant was informed that it is required by law to post the following in the facility:


● Emergency Disaster Plan (LIC 610A) - This must be posted in your home next to the telephone and the Earthquake Preparedness Checklist (LIC 9148), must be attached to the LIC 610A and available to the public.
● Notification of Parents' Rights Poster (PUB 394) - This poster must be placed in an area of the home where all parents can see it
● Facility License, (LIC 203)-Your Family Child Care Home License must be posted in an area of the home where it can be easily seen.
● Notice of Site Visit (LIC 9213) must remain posted for 30 days (during the hours that children are in care) after each site visit by a licensing representative.
● Any licensing report documenting a type “A” citation must be posted for 30 days during the hours that children are in care.
● Any licensing report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

Employee records must be maintained by the applicant and shall contain the following:
LIC9052/Employee Rights, LIC 9108 Mandated Reporter Form, an employment contract or application containing the following information: Employees Full Name, Date of Birth, Driver's License Number, Date of Employment, Documentation of Health and Safety Training, Duties of the employee. Licensee is reminded that records for employees as well as children must be maintained for 3 years after separation from the Family Child Care Home (FCCH). (Page 4)
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
Page: 4 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GUTIERREZ FAMILY CHILD CARE
FACILITY NUMBER: 197494951
VISIT DATE: 04/22/2022
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Mandatory Forms for the Children’s files shall contain the following: LIC 282 Affidavit Liability Insurance, LIC 627/Consent for Medical Treatment, LIC 700/ID and Emergency Information, LIC 995A/Parent's Rights, LIC995E/Caregiver Background Check, LIC 9150/Parent Notification, LIC 9212/Parent's Responsibilities, PM 286/Immunization (Blue) Card.

Applicant also informed children records, and facility roster must be kept for 3 years and advised all public reports must be kept for review. Forms and Regulations available at: www.ccld.ca.gov.



The following was thoroughly discussed with the Applicant:

Applicant was reminded, upon licensure it is the licensee’s responsibility to know the regulations as well as anyone who assists in providing care. Applicant was advised on how to access quarterly reports, forms, and regulations for Child Care online at www.ccld.ca.gov. Applicant was also encouraged to read the Child Care quarterly updates every season as the come out to stay informed of any changes or updates to the regulations.

All adults living and working in the home must be fingerprinted and cleared prior to entering the facility. The Applicant was informed that the presence of adults in the home without Criminal Record Clearance or Exemption will be cited and civil penalty assessed for $100 per day. The Applicant may find additional information and forms on the DSS website at www.ccld.ca.gov including information on the Live Scan application (LIC 9163). Appointments can be made for Live Scan at 1-800-315-4507.
After licensure, Licensee can be cited a civil penalty of $100 per day, up to $500.00 for the 1st offense and up to $3000.00 for the 2nd offense within a 12-month period, PER PERSON.
Upon a finding of noncompliance with a plan of correction for violations of Sections 102419(a)(8), (b), (c), (d), (d)(1), or (d)(2), the Department shall impose a civil penalty of fifty dollars ($50) per day until the deficiency is corrected. Subsequent violations of any provision of these sections within 12 months of the initial citation will result in a civil penalty of $150 plus an assessment of $50 per day until the deficiency is corrected.
(Page 5)
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
Page: 5 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GUTIERREZ FAMILY CHILD CARE
FACILITY NUMBER: 197494951
VISIT DATE: 04/22/2022
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Applicant was made aware of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on childcare licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541
Email Address: childcareadvocatesprogram@dss.ca.gov

Senate Bill 792: Commencing September 1, 2016, SB 792, prohibits a person from being employed or volunteering at a childcare facility or family day care if he or she has not been immunized against influenza, pertussis and measles. LPA discussed the influenza waiver during the inspection.



New Immunization Requirement: Law enacted by SB 277, beginning January 1, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into childcare or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint.

***CCC - Nutrition Requirement: Beginning January 1, 2016, AB 290 will require for each new license issued, at least one director or teacher at each childcare center or family childcare home to have at least one hour of training in the importance of childhood nutrition. This applies to anyone submitting a new application, relocating their facility, selling their facility or transferring their license. Please note this training cannot be completed online or by home study programs. The training must be taken from an Emergency Medical Services Authority (EMSA) approved training program OR an accredited college or university.

Mandated Reporter: Beginning on January 1, 2018, AB 1207, requires all licensed providers, applicants, directors and employees to complete General and Child Care Mandated Reporter training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/.

(Page 6)
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
Page: 6 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GUTIERREZ FAMILY CHILD CARE
FACILITY NUMBER: 197494951
VISIT DATE: 04/22/2022
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The Applicant was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot line at 1-800-540-4000. Also call the CCL office within 24hours of the Unusual Incident and follow up with a written Unusual Incident/Injury Report (LIC 624B) within 7 business days.

Applicant informed Fire disaster drills are to be conducted at least once every month and log must be kept.

Applicant was advised that regulation prohibits the smoking of tobacco in a private residence licensed as a family childcare home during the hours of operation.

Applicant was made aware that state law prohibits baby walkers, bouncy seats, seersuckers and any other items that fall into that category.

Applicant was also reminded that only children eating may be in highchairs and that car seats are utilized only for transportation.

The applicant was advised that, once licensed, the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, (Type A violation), a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed.



LPA discussed AB633 and informed licensee that, upon receipt of a Type A deficiency, the licensee shall post and provide copies of this licensing report to parent/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. Applicant was advised that each parent or child representative must sign the LIC 9224 Acknowledgement of Receipt of Licensing Report and return by the close of the business day or upon the next day the child returns to the facility or upon a newly enrolled child within the next 12 months and place the LIC 9224 in each child's file.
(Page 7)
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
Page: 7 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GUTIERREZ FAMILY CHILD CARE
FACILITY NUMBER: 197494951
VISIT DATE: 04/22/2022
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The following was discussed with the Applicant:
· Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Civil Penalties will be assessed if not in compliance.
· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR training, Immunizations (TDAP, MMR, Influenza), mandated reporter training and a valid criminal record clearance associated to the facility license.
· Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
· The fire extinguisher type 2A:10:BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
· Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
· Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.
· Fire and safety drills must be performed every month and documented for review by the Department.
· Smoking is prohibited in a family childcare home.
· Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
· No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.
· Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
· The facility license number must be on all advertisements, publications or announcements with the intent to attract clients.
· Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home). (Page 8)
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
Page: 8 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GUTIERREZ FAMILY CHILD CARE
FACILITY NUMBER: 197494951
VISIT DATE: 04/22/2022
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· Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for details.

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 also discussed Section 10 of the Application for a Family Child Care Home License that the applicant has signed which states the following:



A. I/We live in the home to be licensed.
B. I/We have money to maintain the level of service required by law in a Family Child Care Home.
C. I/We have both State Fire Marshal approved fire extinguisher (rated 2A:10:BC) and smoke detector in operating condition.
D. I/We shall stay current and in compliance with the law and regulations governing standards for Family Child Care Homes.
E. I/We shall obtain approval from the licensing agency before making changes in our license capacity or to our home.
F. I/We shall notify the licensing agency when we want to discontinue our license.
G. I/We have informed the property owner, if leased or rented, that we will be operating a Family Child Care Home on the premises. The owner/landlord has been sent the Property Owner/Landlord Notification (LIC 9151).
H. I/We have written consent from the property owner, if leased or rented, when I plan to expand my Small Family Child Care Home capacity from 6 to 8 children, or to expand my Large Family Child Care Home capacity to 12 to 14 children. Property Owner/Landlord Consent Form (LIC 9149) has been signed.
I. I/We understand the requirements to report known or suspected child abuse (LIC 9108).
(Page 9)
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
Page: 9 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GUTIERREZ FAMILY CHILD CARE
FACILITY NUMBER: 197494951
VISIT DATE: 04/22/2022
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The applicant’s signature on this report acknowledges that they have signed the Application for a Family Child Care Home License (LIC 279) under the penalty of perjury that the statements on the application and any attachments are correct.

Applicant was provided the following forms/brochures:
PUB 394: Notification of Parents' Rights Poster
LIC 311D: Forms/Records To Keep In Your Family Child Care Home
Copies of All Required Forms/Records for Children and Personnel Listed on the LIC 311D
Effects of Lead Exposure Pamphlet
Effects of Lead Exposure Parent/Representative Signature Form

New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment

At this time, the facility is not ready for a licensure. Based on the LPA’s observation, corrections are needed prior to licensure. The following must be completed within 30 days, no later than 05/23/2022, or the application can be denied:
  1. Securely screen the fireplace in living room #2
  2. Renew Mandated Reporter training and email LPA copy of certificate of completion
  3. Obtain and provide copy of MMR immunization for Applicant and send to LPA to place in Regional Office physical file

Upon completion of the above referenced corrections, the Department will agree to the licensure of a largel family childcare for up to twelve (12) children at a time. MAX. CAPACITY 12 - no more than four infants and eight children; until Landlord Consent (LIC 9149) is received. Once licensed, the Applicant is required to comply with the terms and limitations stated on the license.

Exit interview conducted and a copy of this report was given to the Applicant, Lisset Gutierrez, whose signature confirms today’s Pre-licensing inspection and report.
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SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Keyona ScottTELEPHONE: (424) 301-3091
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
Page: 10 of 10