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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343619154
Report Date: 06/03/2019
Date Signed: 06/03/2019 09:54:45 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:GUTIERREZ, AMYFACILITY NUMBER:
343619154
ADMINISTRATOR:GUTIERREZ, AMYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 363-6180
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY:14CENSUS: 8DATE:
06/03/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Amy GutierrezTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Marea Behvand met with Amy Gutierrez, licensee, for an unannounced random annual visit. Also present was an adult assistant. Eight (8) children were present, including 2 infants. A tour of the home, inside and outside, was conducted.

Off-limit areas are: Garage, all bedrooms, and backyard shed. The back yard is fully fenced, and licensee understands that 100% visual supervision is required in unfenced areas. All adults who work and reside in this facility have fingerprint clearance.

Cleaning compounds, and sharp knives are stored inaccessible to children in care. Smoke detector, carbon monoxide detector and fire extinguisher meet regulations. Toys and play equipment appear to be safe. LPA observed a current CPR/First Aid Certificate, exp. 9/2020. There is a working telephone. Licensee stated that there are no weapons in the home. A review of children’s records was conducted. Children’s files contain signed Emergency Contact Information.

--- Report continues on subsequent pages 809-C and 809-D


SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Marea BehvandTELEPHONE: (916) 216-7793
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2019
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: GUTIERREZ, AMY
FACILITY NUMBER: 343619154
VISIT DATE: 06/03/2019
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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 advised licensee to visit the licensing website at www.ccld.ca.gov for current forms, laws, regulations and legislation. LPA discussed safe sleeping practices for infants. And gave a copy of the Lead Information for licensee to provide to parents.

Appeal rights were discussed, Notice of Site Visit was posted and an exit interview was conducted.

No deficiencies were cited during today inspection.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Marea BehvandTELEPHONE: (916) 216-7793
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2019
LIC809 (FAS) - (06/04)
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