<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313196
Report Date: 01/22/2020
Date Signed: 01/22/2020 03:50:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:GUTIERREZ, SUSANFACILITY NUMBER:
304313196
ADMINISTRATOR:GUTIERREZ, SUSANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 719-3115
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY:14CENSUS: 10DATE:
01/22/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:Susan GutierrezTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Hawkins arrived at the home to conduct a case management inspection. LPA Hawkins conducted an inspection of the home. Upon arrival, LPA met with licensee Susan Gutierrez. Present in the home at the time of visit was her spouse Albert Gutierrez, two adult assistants, and 4 minor children. The overall census observed was 3 adults caring for 10 children (2 infants, 4 preschoolers, 4 school age). A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
LPA toured the home and observed Child #1 (C1) (see attached confidential names LIC 811) in an infant rocker in the family room with a fluffy blanket that could become a potential risk if there is not proper supervision. LPA advised Licensee to be mindful of having objects with infants that could potentially cause suffocation. LPA provided an advisory note.

An exit interview was conducted with Licensee. Report was reviewed and discussed. The licensee was provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights. The first level appeal is to regional manager, address is above on the report. The Notice of Site Visit was posted. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. This report is to be on file and accessible for public review at the facility for at least 3 years.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2020
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 1